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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 207209043
Report Date: 10/13/2021
Date Signed: 10/14/2021 09:53:36 AM

Document Has Been Signed on 10/14/2021 09:53 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: 84DATE:
10/13/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:44 PM
MET WITH:Shawniee Jackson, Executive Director TIME COMPLETED:
02:45 PM
NARRATIVE
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On 10/13/2021, Licensing Program Analyst (LPA) arrived at the facility to conduct a 10-day required site inspection. During the course of the inspection, LPA toured the kitchen and observed the following:
LPA observed boxes blocking pathway to pantry shelves. Plastic bins in the pantry containing pancake mix, and flour were observed to be uncovered and exposed to environment. LPA observed green Jell-O and rice pudding stored in the walk in fridge with no cover, exposed to environment. LPA observed ice cream in freezer to be uncovered.

Based on the LPA's observation, California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87555 was not met. Deficiencies are being cited on the attached LIC 809-D.


Deficiencies are being cited on the attached LIC 809-D.

Exit interview was conducted. A copy of this report and appeal rights were given.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2021
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 10/14/2021 09:53 AM - It Cannot Be Edited


Created By: Lisa Salazar On 10/13/2021 at 01:51 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: 10/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2021
Section Cited
CCR
87555(b)(23)

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87555 General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement was not met as evidenced by Plastic bins in the pantry containing pancake mix, and flour were observed to be uncovered and exposed to environment.
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Facility immediately cleaned the lids that were located on the floor and covered the bins wth tight fitting lids. **POC Cleared**
Type A
10/14/2021
Section Cited
CCR
87555(b)(28)

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 87555 General Food Service Requirements
(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement was not met as evidenced by LPA's observation of green Jell-O and rice pudding stored in the walk in fridge with no cover, exposed to environment. LPA observed ice cream in freezer to be uncovered
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Facility immediately discarded the left over food into the trash bin. *** POC cleared***

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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:Lisa Salazar
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2021


LIC809 (FAS) - (06/04)
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