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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206749
Report Date: 01/04/2024
Date Signed: 01/05/2024 08:26:01 AM


Document Has Been Signed on 01/05/2024 08:26 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:CEDARBROOK MEMORY CARE COMMUNITYFACILITY NUMBER:
107206749
ADMINISTRATOR:SARAH DENNISFACILITY TYPE:
740
ADDRESS:1425 E. NEES AVETELEPHONE:
(559) 412-2299
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:68CENSUS: 58DATE:
01/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrstor, Sarah DennisTIME COMPLETED:
10:45 AM
NARRATIVE
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On 01/04/2024, Licensing Program Analyst (LPA) Gorban conducted a case management in response to incident report regional office received on 09/14/23.

LPA Gorban met with facility Administrator Sarah Dennis, stated the purpose of the visit, and was allowed entry into the facility.

During this visit LPA Gorban toured the facility inside and out, observed residents in care and reviewed residents’ facility files.

LPA discussed with administrator following. Based on department file review facility failed in timely manner, following Title 22, to notify Licensing within seven days incident occurred.

Continuation of this report will be issued during this visit on LIC809-D.

Exit interview conducted. Report signed and a copy of this report with appeal rights provided to administrator for facility records.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024
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 01/05/2024 08:26 AM - 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: CEDARBROOK MEMORY CARE COMMUNITY
FACILITY NUMBER: 107206749

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/05/2024
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements. (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 below. This was not observed as evidenced by:
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By plan of correction facility will ensure to review and follow title 22, reporting requirements and submit to LPA by email written statement 01/05/24.
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Facility failed to submit incident report in timely manner to Licensing, which posses potential safety risk to residents in care.
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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 ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024
LIC809 (FAS) - (06/04)
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