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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 207209043
Report Date: 11/30/2023
Date Signed: 12/04/2023 11:36:33 AM


Document Has Been Signed on 12/04/2023 11:36 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:ELDRIDGE, KIMBERLYFACILITY TYPE:
740
ADDRESS:500 N. WESTBERRY BLVD.TELEPHONE:
(559) 673-2345
CITY:MADERASTATE: CAZIP CODE:
93637
CAPACITY:162CENSUS: 68DATE:
11/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Executive Director- Kelly ReynoldsTIME COMPLETED:
12:15 PM
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On 11/30/23 at 10:31 a.m. Licensing Program Analyst (LPA) B. Miranda entered the facility unannounced to conduct a case management visit regarding an incident report the Department received on 11/27/23. The incident report stated on 11/17/23 the facility received a 7-day shut off notice from PG&E. LPA introduced herself and explained the reason for the visit. LPA met with Executive Director Kelly Reynolds (ED).

LPA conducted a walk around tour of the facility and verified there was no immediate danger.

LPA observed the 7-day notice which had the statement date of 11/17/23 with a due date of 11/29/23. Facility made payment for the full outstanding amount on 11/28/23.

LPA collected the following documents from the visit: Copy of 7-day PG&E notice, and copy of online payment.

LPA asked RCD to provide a statement explaining action taken to prevent the facility from receiving shut off notices, and a statement explaining how this incident reoccurred. LPA explained if the incident report is not correct to send a revised incident report. Statements are due by 12:00 p.m. on 12/1/23.

At this time no citations or civil penalties were issued, citations and civil penalties may be issued at a later date.

Exit interview was conducted and a copy of this report LIC809 was provided to ED Kelly Reynolds.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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