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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 207209043
Report Date: 07/22/2024
Date Signed: 07/28/2024 11:40:57 PM

Document Has Been Signed on 07/28/2024 11:40 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/
DIRECTOR:		ELDRIDGE, KIMBERLYFACILITY TYPE:
740
ADDRESS:500 N. WESTBERRY BLVD.TELEPHONE:
(559) 673-2345
CITY:MADERASTATE: CAZIP CODE:
93637
CAPACITY: 162CENSUS: 87DATE:
07/22/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:05 AM
MET WITH:Executive Director- Kelly ReynoldsTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 7/22/24 Licensing Program Analysts (LPAs) B. Miranda & M. Vega arrived at the facility unannounced to continue the annual inspection. Front desk was informed of the reason for the visit and Executive Director Kelly Reynolds arrived shortly after.

LPAs toured the inside and outside of the facility. When LPAs arrived, breakfast was being served. LPAs observed residents eating and interacting with one another.

LPAs observed the following deficiencies:
  • Waste bag with gloves left outside of resident's room on the second floor
  • Broken glass jar and cleaning supplies in the card room left unlocked and accessible to residents
  • Scissors were left unlocked and accessible to residents in the coffee/tea area to the right of the entrance
  • Kitchen has meat defrosting with blood and not properly stored
  • Freezer has multiple items opened and not stored/closed properly, food items not labeled
  • 1 Strawberry pack was rotting
  • Puddle of water next to the ice machine, mildew inside of the Ice machine
  • Kitchen floors near the stove have debris and oil
  • Window sills in the dining area have debris
  • Cabinets in various areas are unclean and have debris
  • One listed exit route is locked and the outside door is obstructed by chairs

During the tour LPAs observed the facility to be odor free.
Citations were issued per Title 22

Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to
Executive Director Kelly Reynolds.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
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 4
Document Has Been Signed on 07/28/2024 11:40 PM - It Cannot Be Edited


Created By: Brianna Miranda On 07/22/2024 at 12:18 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: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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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. During the tour LPA observed a room listed as a exit that was locked with a key and the door exiting to outside was obstructed by multiple chairs.
POC Due Date: 07/23/2024
Plan of Correction
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Executive Director will provided verification of obstructions being removed verification will be sent to LPA.
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
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. In the card room LPAs observed cleaning items and a broken glass jar under the sink unlocked and accessible to residents. In the coffee and tea area next to the entrance/exit of the facility LPAs observed scissors to be unlocked and accessible to residents in care.
POC Due Date: 07/23/2024
Plan of Correction
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Executive Director will provide verifications items have been removed.
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: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/28/2024 11:40 PM - It Cannot Be Edited


Created By: Brianna Miranda On 07/22/2024 at 12:18 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: 07/22/2024

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
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Based on observation, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPAs observed the following: Puddle of water next to the ice machine, mildew inside of the Ice machine, kitchen floors near the stove have debris and oil, window sills in the dining area have debris, cabinets in various areas are unclean and have debris
POC Due Date: 08/02/2024
Plan of Correction
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Executive Director will provide verification (photos) to LPA.
Type B
Section Cited
CCR
87303(f)(1)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (1) Solid waste shall be stored, located and disposed of in a manner that will not permit the transmission of a communicable disease or of odors, create a nuisance, provide a breeding place or food source for insects or rodents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, 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. LPAs observed the following: Waste bag with gloves left outside of resident's room on the second floor.
POC Due Date: 08/02/2024
Plan of Correction
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Executive Director will provide training to staff and verification will be sent 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: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/28/2024 11:40 PM - It Cannot Be Edited


Created By: Brianna Miranda On 07/22/2024 at 12:18 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: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(23)
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 is not met as evidenced by:
Deficient Practice Statement
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Based on observation, 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 tour LPAs observed the following: Kitchen has meat defrosting with blood leaking from package and not properly stored, freezer has multiple items opened and not stored/closed properly, food items not labeled, and 1 Strawberry pack was rotting
POC Due Date: 08/02/2024
Plan of Correction
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Executive Director will provide training to staff and verification will be sent to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4