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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206749
Report Date: 03/08/2022
Date Signed: 03/08/2022 01:39:37 PM


Document Has Been Signed on 03/08/2022 01:39 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:CEDARBROOK MEMORY CARE COMMUNITYFACILITY NUMBER:
107206749
ADMINISTRATOR:LISA POOLE-JOHNSONFACILITY TYPE:
740
ADDRESS:1425 E. NEES AVETELEPHONE:
(559) 412-2299
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:68CENSUS: 55DATE:
03/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:51 AM
MET WITH:Administrator, Sarah DennisTIME COMPLETED:
11:07 AM
NARRATIVE
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On 03/08/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a Case Management inspection at the above facility. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Sarah Dennis.

The purpose of today’s visit is to follow up on an Incident Report that was submitted to the Fresno CCL office on 02/23/2022.

It was reported that on 02/23/2022 at approximately 09:15AM, S1 “pulled medications for R1, however, S1 administered the medications to R2. Per Administrator, S1 went to retrieve R1’s medication from the med room, R1 attempted to follow the nurse and ended up leaving the area. R2 sat in the chair were R1 was previously sitting. When S1 returned, S1 gave R1’s medications to R2.

Based on interviews and records review, a deficiency is being cited on the attached 809D in accordance with the California Code of Regulations, Title 22, Division 6.

An exit interview was conducted and a Plan of Correction was reviewed and developed with Administrator. A copy of this report and Appeal Rights will be provided to Administrator via email due to COVID-19 precautionary measures. Report signed on-site by Facility Representative.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
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 03/08/2022 01:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: CEDARBROOK MEMORY CARE COMMUNITY
FACILITY NUMBER: 107206749

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2022
Section Cited

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87465 Incidental Medical and Dental Care (a)(4): The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Based on interviews and record reviews, the licensee did not ensure the requirements for the above regulation were met when S1 administered medications that were prescribed to R1 to R2. This poses an immediate health and safety risk to persons in care.
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Licensee stated that facility staff will be trained on the requirements of section 87465. Documentation of training topics and attendance will be submitted to the Fresno CCL office by 04/08/2022.

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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 HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
LIC809 (FAS) - (06/04)
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