107206749-3-8-2022-24-AS-AWAN-CCBTCP-20220308133704

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107206749
Report Date: 03/08/2022
Date Signed: 03/08/2022 01:37:59 PM

Document Has Been Signed on 03/08/2022 01:37 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 COMMUNITY		FACILITY NUMBER:	107206749
ADMINISTRATOR:	LISA POOLE-JOHNSON		FACILITY TYPE:	740
ADDRESS:	1425 E. NEES AVE		TELEPHONE:	(559) 412-2299
CITY:	FRESNO	STATE: CA	ZIP CODE:	93720
CAPACITY:	68	CENSUS: 55	DATE:	03/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:06 AM
MET WITH:	Administrator, Sarah Dennis		TIME COMPLETED:	10:45 AM

NARRATIVE

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On 03/08/2022, Licensing Program Analyst (LPA) A. Walton arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Sarah Dennis.

Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were not observed. 12 bedrooms are single occupant. Beds in the shared apartments were observed to be at least 6 feet apart.

LPA checked residents’ locked medications. LPA observed medication to be removed from the original packaging and placed in small envelopes. LPA confirmed with facility nurse that the medications are removed for approximately 4-5 days. Facility has a 30 day supply of medications. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. Residents wear masks when away from the community. Resident’s files have updated emergency contact information.

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

CONTINUED TO 809C

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (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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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
	VISIT DATE: 03/08/2022

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LPA is requesting the following documents be submitted to the Fresno CCL office by 03/22/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A) Surety Bond.

Exit interview conducted.

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 Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (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

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/08/2022 01:37 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews, the licensee did not comply with the section cited above in when medications for residents were removed from the original packaging and placed in envelopes due to the bottles not fitting in medication cart which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2022
	Plan of Correction
1 2 3 4	Licensee agrees to submit a written statement detailing the steps the facility will take to ensure that the medications are stored in the original container to the Fresno CCL office by 04/08/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (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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