207209043-6-21-2023-24-AS-BCHN-CWB226-20231004170014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 207209043
Report Date: 06/14/2023
Date Signed: 06/21/2023 05:27:45 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
06/12/2023 and conducted by Evaluator Brianna Miranda

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20230612102501

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: 63	DATE:	06/14/2023
		UNANNOUNCED	TIME BEGAN:	01:23 PM
MET WITH:	Resident Care Director- Marilyn Couzens		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Facility staff did not properly manage a resident's medication.

INVESTIGATION FINDINGS:

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On 6/14/2023 at 1:23 p.m. Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to open a complaint and conduct an investigation. LPA met with Resident Care Director Marilyn Couzens and explained the reason for the visit.

LPA collected sample Centerally Stored Medication log, communication log, and Med Tech procedures. Marilyn will provide staff schedule for June and staff contact information by end of business day 6/19/23.

1. The Department investigated the allegation: Facility staff did not properly manage a resident's medication. LPA interviewed staff members and reviewed a sample of resident records. LPA observed Centerally Stored Medication log to not be completed. Bubble packs did not have date medication started and incorrect amount of medication in container.

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: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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 3

Control Number 24-AS-20230612102501

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: 06/14/2023

NARRATIVE

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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 completed and a copy of this report and LIC9099D was provided to Marilyn Couzens

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 24-AS-20230612102501

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: 06/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/15/2023 Section Cited CCR 87465(a)(6)	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	Notice will be given to Med-Techs to properly log medication. All staff meeting on 6/22/23 will have training regarding medication.
	8 9 10 11 12 13 14	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 reviewed Centrally Stored Medication log which was incomplete and amount of medication in container had more medication then should have been from the filled date.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC9099 (FAS) - (06/04)

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