207209043-7-10-2023-24-AS-BCHN-CTQU6B-20230714151805

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 207209043
Report Date: 07/05/2023
Date Signed: 07/10/2023 09:56:29 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
03/29/2023 and conducted by Evaluator Brianna Miranda

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20230329140137

FACILITY NAME:	CEDAR CREEK SENIOR LIVING		FACILITY NUMBER:	207209043
ADMINISTRATOR:	JACKSON, SHAWNIEE		FACILITY TYPE:	740
ADDRESS:	500 N. WESTBERRY BLVD.		TELEPHONE:	(559) 673-2345
CITY:	MADERA	STATE: CA	ZIP CODE:	93637
CAPACITY:	162	CENSUS: 69	DATE:	07/05/2023
		UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Senior Director of Sales & Marketing Gaby Alvarado		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff did not safeguard resident's records
Staff do not provide adequate supervision to prevent residents from leaving the facility

INVESTIGATION FINDINGS:

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On 7/5/2023 at 1:50 p.m. Licensing Program Analyst B. Miranda arrived to the facility unannounced to deliver the finding for the allegations listed above. LPA introduced herself and explained the reason for the visit and met with Senior Director of Sales & Marketing Gaby Alvarado

1. The Department investigated the allegation: Staff did not safeguard resident's records. During a tour of the facility LPA noticed the top half of the Medication room was not locked and was able to be unlocked from the bottom and client's records were accessible. Administrator (Shawniee Jackson) asked staff why the medication door was left open, and staff stated because they just came out of the Med Room. LPA observed Med-Tech walking from an area of a resident's rooms and not the med room.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

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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Control Number 24-AS-20230329140137

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 07/05/2023

NARRATIVE

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2. The Department investigated the allegation: Staff do not provide adequate supervision to prevent residents from leaving the facility. During an interview with the Administrator (Shawniee Jackson), stated a resident has been able to get outside the facility through the front doors and into the parking lot. This resident belongs to memory care and should be accompanied by staff when leaving memory care. Administrator stated the furthest any resident has been able to get is the parking lot. LPA asked if the incidents were reported and Administrator stated no because they did not know they had to. LPA explained anytime an incident occurs and a resident is some where they are not supposed to be it should be reported to licensing.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D

Exit interview was conducted. A copy of LIC9099, LIC9099C, and LIC9099D have given to Gaby Alvarado

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20230329140137

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/14/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Ensuring staff are aware of who residents are in Generations. Verification of in-service/memo will be sent to LPA.
	8 9 10 11 12 13 14	Based on observation and interview, 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. Administrator at the time informed LPA resident from Generations (Memory Care) was able to get out the facility and into the parking lot without staff being aware.	8 9 10 11 12 13 14
Type B 07/14/2023 Section Cited CCR 87506(c)(1)	1 2 3 4 5 6 7	87506 Resident Records (c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will have in-service/memo with Med-Tech staff. Verification of in-service/memo will be sent to LPA.
	8 9 10 11 12 13 14	Based on observation and interview, 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 observed door not locked where resident's records are kept making them accessible to anyone.	8 9 10 11 12 13 14

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 Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

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