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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 207209043
Report Date: 07/05/2023
Date Signed: 07/10/2023 12:12:25 AM

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
03/06/2023 and conducted by Evaluator Brianna Miranda
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230306123828
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: 69DATE:
07/05/2023
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Senior Director of Sales & Marketing Gaby AlvaradoTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Staff are not following Covid-19 masking protocols
Staff do not follow procedures which protect the safety of food during preparation and service.
Facility is dirty.
Staff do not respond to resident's requests for assistance in a timely manner.
Staff do not ensure that resident is given the correct medication.
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 with Senior Director of Sales & Marketing Gaby Alvarado.

1. The Department investigated the allegation: Staff are not following Covid-19 masking protocols. LPA toured the facility and found some employees to either not be wearing a mask or wearing the mask incorrectly. At this time is was still mandatory for all employees to wear masks while working in the facility.

2. The Department investigated the allegation: Staff do not follow procedures which protect the safety of food during preparation and service. LPA toured the facility on various occasions and found kitchen staff to not be wearing gloves while preparing food and to be without hairnets. LPA requested multiple time for training of kitchen staff and kitchen staff contact information which was never provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 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)
Page: 1 of 5
Control Number 24-AS-20230306123828
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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3. The Department investigated the allegation: Facility is dirty. 4 Staff interviews were conducted and LPA observed areas of the facility not being maintained. Widow sills in the dining area need to be cleaned. Madera room needs to be cleaned and maintained residents are able to access room. Ice machine has mold and kitchen needs to be cleaned and maintained.

4. The Department investigated the allegation: Staff do not respond to resident's requests for assistance in a timely manner. LPA observed call pendent logs which showed at times calls were not being answered timely and would take up to an hour after the button was pushed to respond.

5. The Department investigated the allegation: Staff do not ensure that resident is given the correct medication. LPA conducted 3 interviews and observed MARS and centrally stored medication log. Centrally stored medication log was not completed and MARs was not being completed properly. LPA and staff were unable to verify start dates for some medication and bubble packs showed medication was not taken and there was no documentation.

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 and a copy of this report, LIC9099C, & LIC9009D were provided to Senior Director of Sales & Marketing Gaby Alvarado.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 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)
Page: 2 of 5
Control Number 24-AS-20230306123828
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 A
07/06/2023
Section Cited
CCR
87555
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87555 General Food Service Requirements
(b) The following food service requirements shall apply:
(9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.
This requirement is not met as evidenced by:
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Facility will schedule an inservice meeting regarding issues in the kitchen.
Inservice meeting will be conduct by 7/14/23 and verification will be sent to LPA by 7/14/23.
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Based on observation interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed kitchen staff while preparring food to not be wearing gloves or hairnets.
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Type A
07/06/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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Ice machince will be shut off to allow ice to melt and have a deep cleaning.

Meet with Maintance and schedule cleaning of areas listed.
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Based on observation interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed dirty widow sills in the dining area, Madera room is dirty (needs be cleaned and maintained due to residents having access room), ice machine has mold, and kitchen needs to be cleaned and maintained.
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On or before 7/14/23 items listed will be cleaned and verification will be sent to LPA.
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: 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)
Page: 3 of 5
Control Number 24-AS-20230306123828
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 A
07/06/2023
Section Cited
CCR
87465(a)(6)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
This requirement is not met as evidenced by:
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Facility will submit plan to correct issue.

Plan/training will be completed by 7/14/23. Verification will be sent to LPA
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Based on observation interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed resident medication logs which were not completed properly. Staff could not explain why medication had not been given to resident.
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Type A
07/06/2023
Section Cited
CCR
87468.1(a)(2)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
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Facility will submit plan to correct issue.

Plan/training will be completed by 7/14/23. Verification will be sent to LPA
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Based on observation interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed pendent logs which indicated there are times resident had to wait up to an hour to be assisted.
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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: 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)
Page: 4 of 5
Control Number 24-AS-20230306123828
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
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
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Memo will be issued to employees to remind of infection control policies.
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Based on observation, 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. During the tour of the facility LPA observed Kitchen manager in the kitchen with the mask under their chin, 1 staff member in an office coming in and out of the office without a mask, 1 contracted maintenance person without a mask. As LPA observed 2 more staff members wearing masks under their nose.
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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: 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)
Page: 5 of 5