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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 207209043
Report Date: 03/10/2023
Date Signed: 03/13/2023 07:19:53 AM


Document Has Been Signed on 03/13/2023 07:19 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: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:
03/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Administrator Shawniee JacksonTIME COMPLETED:
03:00 PM
NARRATIVE
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On 3/10/2023 at 1:10 p.m. Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to conduct a Case Management. Case Management is being conducted in response to information received on 3/8/2023 regarding a previous outbreak at the facility from 11/2022-12/2022. LPA was greeted by receptionist and allowed entry into the facility. LPA requested to speak with Administrator (AD) Shawniee Jackson. AD was contacted and met with LPA. LPA explained the reason for the visit.

LPA reviewed previously submitted incident reports from the facility and the Covid-19 log kept at the facility. The number of positive Covid-19 cases listed on the incident report and sent to CCLD do not match the number of positive cases listed on the log. The log indicates for the month of November 2022 there were 33 positive Covid-19 cases from 11/6/22-11/11/22.

Citation was issued today under Title 22, Division 6, Chapter 8, Article 04, Operating Requirements

Exit interview was completed. A copy of this report and LIC809D were provided to AD.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023
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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Document Has Been Signed on 03/13/2023 07:19 AM - 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: CEDAR CREEK SENIOR LIVING
FACILITY NUMBER: 207209043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2023
Section Cited

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.

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AD agrees to submit a statement of understanding of CCLD PINs and submit to CCLD by due date.
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This requirement is not met as evidenced by:
Based on observation, interview, and file review the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
LPA reviewed documents which did not match the number of positive COVID-19 cases with the number of cases reported to CCLD (Outbreak)
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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) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023
LIC809 (FAS) - (06/04)
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