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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 207209043
Report Date: 08/24/2023
Date Signed: 08/25/2023 02:12:33 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
05/01/2023 and conducted by Evaluator Brianna Miranda
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230501112552
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: 65DATE:
08/24/2023
UNANNOUNCEDTIME BEGAN:
01:08 PM
MET WITH:Resident Care Director- Kimberly JonesTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff does not ensure resident's pressure injury is cleaned.
Staff does not respond to resident's call button in a timely manner.
Facility does not have adequate staffing to meet resident's needs.
INVESTIGATION FINDINGS:
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On 8/24/23 at 1:08 p.m. Licensing Program Analyst B. Miranda arrived to the facility unannounced to deliver the findings of the allegations listed above. LPA introduced herself to receptionist and requested to speak with the Administrator Joan Johnson. Receptionist stated Administrator was not available and all other managers were not available. Marketing Director contacted Resident Care Director (RCD) Kimberly Jones who arrived shortly after. LPA met with RCD and explained the reason for the visit.
1. The Department investigated the allegation: Staff does not ensure resident's pressure injury is cleaned. LPA conducted interviews and reviewed records. Facility was not able to provide Healthcare Plan which includes services that are provided by Home Health and which services are provided by the facility including the duration of the services. Communication log indicates there was discrepancies in Home Health Providers and resident was not getting proper care for pressure injuries. Resident was receiving care from Bridge Home Health, notes indicate facility did not know resident was discharged from Bridge Home Health since 3/28/23. LPA observed notes indicating St. Mary's Home Health, but no documents.
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: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
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 4
Control Number 24-AS-20230501112552
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: 08/24/2023
NARRATIVE
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LPA observed documents from Valley Home Health signed 4/20/23, but no notes regarding status of care.
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

2. The Department investigated the allegation: Staff does not respond to resident's call button in a timely manner. LPA conducted interviews and reviewed records. Records show there were multiple times the resident had to wait over 18 minutes from the time R1's pendant had been pushed. Interviews conducted stated the facility is short staffed so it takes longer to respond to the residents when the pendants are pushed.


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.

3. The Department investigated the allegation: Facility does not have adequate staffing to meet resident's needs. LPA conducted interviews where it was stated the facility is short staffed so it is hard to meet the resident's needs adequately. On 4/12/23 communication log indicates R1's catheter was leaking and a pressure injury on the buttocks was turning green and smelly. However staff did not send resident to the hospital and facility was unaware home health services were discontinued.

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.

During the course of this complaint investigation LPA interviewed staff on duty and obtained and/or reviewed facility records. It was determined based on the interviews and records review that the above allegations are SUBSTANTIATED.



Exit interview was conducted and a copy of this report LIC909 , LIC9099D, and appeal rights were given to Resident Care Director- Kimberly Jones.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20230501112552
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: 08/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2023
Section Cited
CCR
87609(b)(2)
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87609 Allowable Health Conditions and the Use of Home Health Agencies (b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (2) The licensee provides the supporting care and supervision needed to meet the needs of the resident receiving home health care.
This requirement is not met as evidenced by:
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RCD will create a binder with plans and note care of service. Policy & procedure verification will be sent to LPA 8/31/23.
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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. Facility did not take the proper steps to ensure R1's medical needs were being met with Home Health, and no completed health plan was on file.
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Type A
08/25/2023
Section Cited
CCR
87623(b)(2)
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87623 Indwelling Urinary Catheter
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (2) Ensuring that the bag and tubing are changed by an appropriately skilled professional should the resident require assistance. (B) There shall be written documentation by an appropriately skilled professional outlining the instruction of the procedures delegated and the names of the facility staff who have been instructed.
This requirement is not met as evidenced by:
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Staff will be inserviced on home health policy. Knowing when to call home health and send out. Home health contact information will be noted on service plan and service agreement.
Policy/Procdure will be provided to LPA by 8/31/23.
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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. Staff at the facility was not adequate to care for R1 and send to hospital when needed. Interviewees stated facility was short staff and unable to meet resident's needs.
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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: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20230501112552
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: 08/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2023
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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Escalation procedure in place. After 15 minutes the call is escalated to GPD & RCD.
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Based on observation interview, the licensee did not comply with the section cited above Poses a potential health, safety, or personal rights risk to residents in care.
LPA reviewed records which indicated there was an extended amount of time before R1's pendant call was responded to.
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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: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4