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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 207209043
Report Date: 06/14/2023
Date Signed: 06/29/2023 12:31:41 PM

Document Has Been Signed on 06/29/2023 12:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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:
06/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:19 PM
MET WITH:Resident Care Director- Marilyn CouzensTIME COMPLETED:
04:30 PM
NARRATIVE
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On 6/14/2023 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct a case management. LPA met with Resident Care Director Marilyn Couzens introduced herself, and explained the reason for the visit.

During the visit LPA was informed Administrator Shawinee Jackson was not longer the administrator and S1 was the Interim Administrator. LPA reviewed records and did not find S1 to have proper clearance to work at the facility. Citation was issued under Title 22, Division 6, Chapter 8.

Exit interview was conducted, a copy of this report and LIC809D were provided to Marilyn Couzens.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 06/29/2023 12:31 PM - It Cannot Be Edited


Created By: Brianna Miranda On 06/14/2023 at 03:27 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: 06/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2023
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or
This requirement is not met as evidenced by:
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S1 will have to leave the facility and will not be able to return until back ground clearance has been completed.
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Based on observation interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed uncleared staff S1 to be in the facility without proper clearance.
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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:Brenda Chan
LICENSING EVALUATOR NAME:Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023


LIC809 (FAS) - (06/04)
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