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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 207209043
Report Date: 11/07/2024
Date Signed: 11/07/2024 12:21:44 PM

Document Has Been Signed on 11/07/2024 12:21 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:
11/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator Kelly ReynoldsTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On 11/7/24 Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to conduct a case management visit. LPA met with Administrator Kelly Reynolds and explained the reason for the visit.

LPA reviewed R1's file which contains R1's admission agreement showing when R1 signed the admission agreement they were their own responsible party.

LPA reviewed copies of outstanding notices previously given to R1. Statements show a reoccurring balance on each statement, and AD stated there have been multiple verbal conversation with R1 and Ombudsman regarding the situation.


LPA inquired on a death report received for R2 on 10/6/2024. R2 passed on 9/26/24 and a written report should be submitted within 7 days. The 7th day from 9/26/24 would have been 10/3/2024. Deficiency was cited under Title 22.


Exit interview was conducted and a copy of this report LIC809, LIC809D, LIC421FC, and appeal rights were provided to Kelly Reynolds.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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 11/07/2024 12:21 PM - It Cannot Be Edited


Created By: Brianna Miranda On 11/07/2024 at 11:38 AM
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: 11/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2024
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(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 specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
This requirement is not met as evidenced by:
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Administrator will meet with staff who submits reports to the Dept.
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Based on observation, interview, & record review the licensee did not comply with the regulations listed above. This poses a potential health, safety, or personal rights risk to residents in care. The Administrator did not comply with the regulation listed above due to R2's death report not being submitted to the Dept within the required 7 days.
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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: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
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