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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 207209043
Report Date: 03/07/2023
Date Signed: 03/07/2023 04:12:57 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/11/2022 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20221011105453
FACILITY NAME:CEDAR CREEK SENIOR LIVINGFACILITY NUMBER:
207209043
ADMINISTRATOR:JACKSON, SHAWNIEEFACILITY TYPE:
740
ADDRESS:500 N. WESTBERRY BLVD.TELEPHONE:
(559) 673-2345
CITY:MADERASTATE: CAZIP CODE:
93637
CAPACITY:162CENSUS: 76DATE:
03/07/2023
UNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Shawniee Jackson, Executive Director TIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained injuries from falls while in care
Staff mishandled a resident's medication
Staff overmedicated a resident while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 03/07/23, Licensing Program Analyst (LPA), L. Salazar arrived to the facility unannounced to deliver findings on the above allegations. LPA was greeted by receptionist, stated the purpose of the visit and was allowed entry into the facility.

During the investigation, LPA conducted interviews and records review. Based on the information received and although the allegations may have happened, there is not a preponderance of evidence to prove that the alleged violations occurred, therefore the allegations are Unsubstantiated.

When Resident R1 was admitted to hospice care services, the facility did not receive a discontinue order for medications. Facility was continuing to follow doctor's order. Facility provided extra care and supervision and documented contact with the hospice agency regarding R1's condition. No deficiencies cited. Exit interview conducted and copy of report was left with Executive Director.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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