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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206749
Report Date: 01/31/2023
Date Signed: 02/14/2023 11:13:36 AM


Document Has Been Signed on 02/14/2023 11:13 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: 59DATE:
01/31/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Manager on duty, Narissa Rodriguez.TIME COMPLETED:
09:31 AM
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On 01/31/2023 Licensing Program Analyst (LPA) V Gorban arrived at the facility to complete an unannounced case management visit. LPA’s met Manager on duty Narissa Rodriguez. Administrator Sarah Dennis was contacted but was not available at the time. LPA was given permission to complete tour of the facility with 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.

LPA is completing visit on a case management for a Special Incident Report (SIR) Community Care Licensing (CCL) received. LPA reviewed resident file and staff training and credentials. LPA collected files for facility folder records. LPA is advising facility to update Needs and Services plan for fall risk residents and keep them in the residents folder. Updated Needs and Services Plan submit to Licensing no later then 02/15/2023

Residents files picked by LPA are: 17B, 6P, 34A, and 8B

No citations were issued on this this visit.

Exit interview conducted and copy of this report provided to manager on duty for facility records.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
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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