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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206749
Report Date: 04/03/2024
Date Signed: 04/04/2024 08:02:40 AM


Document Has Been Signed on 04/04/2024 08:02 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:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Administrator Sarah DennisTIME COMPLETED:
11:30 AM
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On 04/03/2024, Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct Required Annual Inspection. LPA was greeted by receptionist and stated the purpose of the visit. LPA met with Administrator (AD) Sarah Dennis, certification number 6050734740 and expiration date 2/04/2025. LPA conducted tour of facility with AD. Residents were observed at the facility during breakfast and in common areas.
The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 006/06/2023.

Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer, walk-in refrigerator, and pantry. Food is delivered twice a week on Mondays and Thursdays. Refrigerator temperature was maintained at 32-degree F. and freezer was maintained at 0-degree F.

LPA toured a sample of resident bedrooms. Residents' rooms were observed with adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested at 106 degrees F. LPA observed securely fastened grab bars and non-skid mat in all shower areas.

Medications were stored in a locked medication room in a medication cart. Medications records were reviewed in AugustHealth. First Aid Kit was stored in medication room and observed with all required items. LPA toured laundry room and observed chemicals were stored and locked.

Facility courtyard was toured and observed to be free from debris. There was outdoor seating available for the residents.

Report continues on LIC809-C

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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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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
VISIT DATE: 04/03/2024
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A sample of residents’ files were reviewed to have updated emergency contact, Admission agreement, Needs and Services Plan and Pre-Appraisal Plan. A sample of staff files were reviewed. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel record. Staff are fingerprinted clear and associated to the facility.

An exit interview was conducted with the AD. The following documents are requested and submitted to Fresno CCL by: 04/10/24 :

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Administrator Certificate
· Alternate contact information including name, telephone number, & email address.

No deficiencies issued during this inspection.

A copy of this report was given to the AD, whose signature on this form confirm receipt of this report.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
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