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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 207209043
Report Date: 09/29/2021
Date Signed: 10/28/2021 10:33:34 AM

Document Has Been Signed on 10/28/2021 10:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:CEDAR CREEK SENIOR LIVINGFACILITY NUMBER:
207209043
ADMINISTRATOR:JACKSON, SHAWNIEEFACILITY TYPE:
740
ADDRESS:500 N. WESTBERRY BLVD.TELEPHONE:
(559) 673-2345
CITY:MADERASTATE: CAZIP CODE:
93637
CAPACITY: 162CENSUS: DATE:
09/29/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:58 PM
MET WITH:Executive Director, Shawniee JacksonTIME COMPLETED:
05:44 PM
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On 9/29/2021 Licensing Program Analyst (LPA) M. Garza arrived at facility and met with Executive Director (ED), Shawniee Jackson for a case management to return files. Upon entry into the facility LPA observed construction work that has taken place in the faciilty and office area. The sheet rock was removed and exposing the 2x4's inside the walls. LPA addressed reporting with ED.

LPA also addressed a SOC 341 that was submitted by a third party on 9/10/2021 for Resident (R1). During LPA observation it was noted that this incident was not reported to CCL.

The following deficiencies are being cited: Title 22, Division 6, Chapter 8, Section 87211(a)(1)(D). Refer to 809D. A plan of correction was discussed with the Executive Director. An exit interview was conducted. Appeal Rights discussed.

A copy of this report and Appeal Rights were emailed due to COVID precautionary measures being taken. A delivered and read receipt serves as confirmation.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/28/2021 10:33 AM - It Cannot Be Edited


Created By: Mary Garza On 09/29/2021 at 05:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CEDAR CREEK SENIOR LIVING
FACILITY NUMBER: 207209043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2021
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports...: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events... (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.




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The POC from ED is to have training completed on 10/5 and 10/6/21 for the ED and Licensing Vocational Nurse (LVN). Complete training with all other staff and documentation sent to CCL no later than 10/17/21. Continue ongoing training/education with all staff regarding mandated reporters and elderly abuse every 6 months with documentation submitted to CCL.
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This requirement was not met as evidence by:
Interview conducted with Executive Director and observation that no verification the incident was reoirted or submitted to CCL.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Melinda Hoffmann
LICENSING EVALUATOR NAME:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2021


LIC809 (FAS) - (06/04)
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