<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206749
Report Date: 05/21/2024
Date Signed: 05/21/2024 04:15:14 PM


Document Has Been Signed on 05/21/2024 04:15 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: 60DATE:
05/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator, Sarah DennisTIME COMPLETED:
10:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 5/21/2024, Licensing Program Analyst (LPA) V Gorban visited the facility to conduct case management to he incident that occurred on 5/11/2024 with resident (R1). During this visit LPA met with Administrator, Sarah Denis stated the purpose of the visit.

During this visit LPA toured the facility conducting safety check and interviewed staff and Administrator. Based on incident report provided to Licensing on 5/17/24, R1 increased lethargy and decreased in responsiveness. Per report, based on that observation the facility contacted responsible party at 1645. Per report, responsible party did not agree to sent R1 out for evaluation.
Per report, at 17:37 EMS was assessing R1 at the facility.
During this visit LPA requested additional facility files for review.

No deficiency was cited during this visit
Exit interview conducted, report signed and copy provided for facility records.



SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1