<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 207209043
Report Date: 06/29/2023
Date Signed: 09/28/2023 04:57:58 AM


Document Has Been Signed on 09/28/2023 04:57 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: 62DATE:
06/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:34 AM
MET WITH:Resident Care Director- Marilyn CouzensTIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 6/29/23 at 11:35 a.m. Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct a case management regarding the administrator at the facility. LPA introduced herself and explained the reason for the visit. Resident Care Director (RCD) Marilyn Couzens was contacted.

Previously on 6/14/23 LPA was informed Administrator on file Shawniee Jackson is longer working at the facility. LPA was informed Shawniee’s last day at the facility was 5/30/23. Facility has 30 days to provide proper verification of a certified Administrator, which will end 6/30/23

Facility has not provided verification of certified administrator at this time.

Facility was informed verification needs to be provided by end of business day 7/3/23.

Exit interview was conducted and a copy of this report was provided to Marilyn Couzens.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1