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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206749
Report Date: 12/19/2022
Date Signed: 12/20/2022 01:24:26 PM


Document Has Been Signed on 12/20/2022 01:24 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: 55DATE:
12/19/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Executive Administrator, Sarah DennisTIME COMPLETED:
11:15 AM
NARRATIVE
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On 12/19/2022 Licensing Program Analyst (LPA) V Gorban arrived at the facility to complete an unannounced case management visit. LPA’s met Executive Director Sarah Dennis. LPA was given permission to complete tour of the facility with Sarah Dennis. LPA explained reason for visit, COVID pre-screened at entry into the facility and permitted entry. LPA toured facility and completed a health and safety check on residents in care. Resident observed in common area.

LPA is completing visit on a case management for a Special Incident Report (SIR) Community Care Licensing (CCL) received. SIR stated R1 was administered medications belong to R2. This poses a potential health/safety or personal rights risk to residents in care. Repeat violation. Civil penalty will apply. Deficiencies cited on LIC 809D per Title 22 regulations.

Exit interview completed with Executive Administrator Sarah Dennis .

A copy of this report, deficiency and appeal rights provided to Sarah Dennis.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2022
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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Document Has Been Signed on 12/20/2022 01:24 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: 12/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/19/2022
Section Cited

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87465 Incidental Medical and Dental Care (a)(4): The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Training was submitted to department for Medication Administration requirements. POC was cleard on site.
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Based on record review, the facility did not ensure the requirements for section 87465(a)(4) were met when facility staff administered medications belonging to R1 to R2, which poses an immediate health and safety risk to residents in care.
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Executive Director of Resident stated that all staff will be monitored closely on medication administration. A copy of training and administration topics will be emphasized to staff continuously on monthly meetings.

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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: 12/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2022
LIC809 (FAS) - (06/04)
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