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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
207209043
Report Date:
11/16/2023
Date Signed:
12/04/2023 11:47:49 AM
Document Has Been Signed on
12/04/2023 11:47 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
SIERRA CASCADE AC/SC
,
1314 E SHAW AVE
FRESNO
,
CA
93710
FACILITY NAME:
CEDAR CREEK SENIOR LIVING
FACILITY NUMBER:
207209043
ADMINISTRATOR:
JACKSON, SHAWNIEE
FACILITY TYPE:
740
ADDRESS:
500 N. WESTBERRY BLVD.
TELEPHONE:
(559) 673-2345
CITY:
MADERA
STATE:
CA
ZIP CODE:
93637
CAPACITY:
162
CENSUS:
72
DATE:
11/16/2023
TYPE OF VISIT:
Case Management - Annual Continuation
UNANNOUNCED
TIME BEGAN:
10:15 AM
MET WITH:
Executive Director Kelly
TIME COMPLETED:
05:20 PM
NARRATIVE
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On 11/16/23 Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to completed the annual inspection which was originally started on 7/27/23. Management companies have changed and Kimberly Jones is no longer at the facility since 11/1/23. LPA spoke with Kelly Metz and Kimberly Eldridge.
LPA had previous conducted the tour on 7/27/23 and was at the facility today to complete the care tool part of the annual inspection.
During the visit on 7/27/23 facility was not able to provide current annual training for staff members
Facility was not able to provide current first aid/CPR cards for staff members. Updated cards were provided today
Plan of operation is to be readily available at the facility and it was not.
On 7/27/23 LPA observed various areas of the facility needing to be cleaned
On 7/27/23 LPA found cleaning products & scissors not locked away and available to residents in care in the Generations area of the facility.
On 7/2/23 LPA observed kitchen staff to not be wearing gloves when handling food items and food items subject to cross contamination due to being stored improperly
Emergency contact information is not up to date in resident's charts.
Modifications were not attached to resident's admission agreements
Kitchen cleaning supply closet could not properly close
Citations were issued today and have been entered into LIC809D.
Exit interview was completed. A copy of this report LIC809, LIC 809D, and appeal right were provided to Kelly.
SUPERVISORS NAME
:
Brenda Chan
LICENSING EVALUATOR NAME
:
Brianna Miranda
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/25/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/25/2023
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
7
Document Has Been Signed on
12/04/2023 11:47 AM
- It Cannot Be Edited
Created By:
Brianna Miranda
On
11/16/2023
at
01:47 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:
11/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
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. During the tour of the facility LPA found cleaning supplies and scissors to be not be locked and accessible to residents in the Generation area of the facility.
POC Due Date:
11/17/2023
Plan of Correction
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2
3
4
State will be provided itesm have been removed by Exectuative Director Kelly. Copy of statement will be sent to LPA.
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. After reviewing a sample of the staff records facility was unable to provide current/valid First Aid/CPR cards for staff members.
POC Due Date:
11/17/2023
Plan of Correction
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4
Facility provided current and valid First Aid/CPR cards for staff members.
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:
11/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/16/2023
LIC809
(FAS) - (06/04)
Page:
2
of
7
Document Has Been Signed on
12/04/2023 11:47 AM
- It Cannot Be Edited
Created By:
Brianna Miranda
On
11/16/2023
at
01:47 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:
11/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(28)
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 is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
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 food not being properly stored and staff not using gloves when handling food on 7/27/23.
POC Due Date:
11/17/2023
Plan of Correction
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2
3
4
Staff inservice will be completed and verification will be provided to LPA. Verification of in service will be provided by 11/22/23.
Type A
Section Cited
CCR
87555(b)(23)
(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 is not met as evidenced by:
Deficient Practice Statement
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4
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. Meat was not properly stored in the refrigerator with other food.
POC Due Date:
11/17/2023
Plan of Correction
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3
4
Staff inservice will be completed and verification will be provided to LPA. Verification of in service will be provided by 11/22/23.
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:
11/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/16/2023
LIC809
(FAS) - (06/04)
Page:
3
of
7
Document Has Been Signed on
12/04/2023 11:47 AM
- It Cannot Be Edited
Created By:
Brianna Miranda
On
11/16/2023
at
01:47 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:
11/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(f)(1)
Incidental Medical and Dental Care Services
(f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed a sample of the resident's charts which did not have current emergency contact information.
POC Due Date:
11/23/2023
Plan of Correction
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4
Since 7/27/23 visit facility has created and obtained a resident roster for emergency purposes. POC will be cleared.
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Facility did not have on file Plan of Operations located at the facility.
POC Due Date:
11/23/2023
Plan of Correction
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Facility is currently in the process of obtained plan of operation and will provide copy to LPA. A copy will remain at the facility.
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:
11/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/16/2023
LIC809
(FAS) - (06/04)
Page:
4
of
7
Document Has Been Signed on
12/04/2023 11:47 AM
- It Cannot Be Edited
Created By:
Brianna Miranda
On
11/16/2023
at
01:47 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:
11/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed cabinets in the Madera Room needing to be cleaned and the kitchen/cabinets in Generations needing to be cleaned.
POC Due Date:
11/23/2023
Plan of Correction
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4
Facility will be looking at housekeeping schedules to include common areas are addressed. Verification will be sent to LPA.
Type B
Section Cited
CCR
87506(b)(13)
Resident Records
(b) Each resident's record shall contain at least the following information: (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or the services he needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA reviewed a sample of resident's charts which do not have current physician's report for residents with dementia.
POC Due Date:
11/23/2023
Plan of Correction
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2
3
4
Facility is in the middle of auditing files and will have files updated. LPA will be informed when the process is completed.
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:
11/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/16/2023
LIC809
(FAS) - (06/04)
Page:
5
of
7
Document Has Been Signed on
12/04/2023 11:47 AM
- It Cannot Be Edited
Created By:
Brianna Miranda
On
11/16/2023
at
01:47 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:
11/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(d)
Admisson Agreements
(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA did not observe any modification to admission agreements when rent is increased or if change of status creates an increase.
POC Due Date:
11/23/2023
Plan of Correction
1
2
3
4
Provide a statement stating modification will be kept with admission agreement files. Verification will be sent to LPA.
Type B
Section Cited
CCR
87555(b)(22)
General Food Service Requirements
(b) The following food service requirements shall apply: (22) Adequate space shall be maintained to accommodate equipment, personnel and procedures necessary for proper cleaning and sanitizing of dishes and other utensils.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation & interview, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed storage closet with cleaning supplies was not able to close properly.
POC Due Date:
11/23/2023
Plan of Correction
1
2
3
4
State will be provided regarding closet being arranged and will close properly. Picture will be provided to LPA.
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:
11/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/16/2023
LIC809
(FAS) - (06/04)
Page:
6
of
7
Document Has Been Signed on
12/04/2023 11:47 AM
- It Cannot Be Edited
Created By:
Brianna Miranda
On
11/16/2023
at
01:47 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:
11/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed various areas of the kitchen to not be cleaned, sanitized, and to have debris buildup.
POC Due Date:
11/23/2023
Plan of Correction
1
2
3
4
Weekly and additional cleaning has been put into place. Third partly company will come quarterly to thoroughly clean.
Type B
Section Cited
HSC
1569.695(e)(1)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (1) A resident roster with the date of birth for each resident.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. During the visit on 7/25/23 facility was not able to provide a roster of residents readily available in case of an emergency.
POC Due Date:
11/23/2023
Plan of Correction
1
2
3
4
POC has been cleared. On 11/16/23 visit, facility now has a resident roster readily available.
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:
11/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/16/2023
LIC809
(FAS) - (06/04)
Page:
7
of
7