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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206749
Report Date: 02/26/2024
Date Signed: 02/26/2024 04:34:19 PM


Document Has Been Signed on 02/26/2024 04:34 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: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: 59DATE:
02/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:27 PM
MET WITH:Samantha Keith, Director of Resident ServicesTIME COMPLETED:
02:10 PM
NARRATIVE
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On 02/26/24, Licensing Program Analyst (LPA) V Gorban conducted a case management deficiency visit to the facility. LPA introduce self, stated the purpose of the visit, and met with Samantha Keith, Director of Resident Services.
The purpose of the visit is to address an incident that occurred where R1 went AWOL on 02/17/24.
The facility was unaware when R1 AWOL the facility. Residents file review stated resident is dementia and unable to leave facility unassisted.

Therefore, as a result, a deficiency is being cited, per California
Code of Regulations, Title 22, Division 6, see attached 809D.

An exit interview was conducted. A copy of this report and appeal rights was provided to Director of Resident Services, whose signature confirms receipt of this report.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024
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 02/26/2024 04:34 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
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: 02/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/27/2024
Section Cited
CCR
87413(a)(2)

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87413(a) In each facility (2) Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice.
This requirement was not met as evidenced by:
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Administrator and Director of Resident Services offered to provide staff training / in-service, also ensure that facility doors are locked and secured correctly. Deficiency was cleared at the time of the visit.
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Based on interview and record review, staff did not provide care and supervision when memory care R1 left the facility unsupervised on 02/17/24 at unknown time or approximately 8:38 PM. The facility was not aware R1 went AWOL until approximately at 10:15 PM Fresno PD notified the facility. This is poses an immediate health and safety risk to persons 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: 02/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024
LIC809 (FAS) - (06/04)
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