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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 207209043
Report Date: 10/09/2023
Date Signed: 11/28/2023 09:57:51 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
08/07/2023 and conducted by Evaluator Brianna Miranda
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230807083425
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: 68DATE:
10/09/2023
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Resident Care Director- Kimberly JonesTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not properly notify resident's responsible party of rate increase.
Staff did not allow resident’s responsible party to participate in decision-making regarding the care and services provided to the resident.
INVESTIGATION FINDINGS:
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On 10/9/2023 Licensing Program Analyst B. Miranda arrived at the facility unannounced to deliver the finding for the allegations listed above. LPA introduced herself and explained the reason for the visit. Resident Care Director (RCD) Kimberly Jones was contacted and met with LPA.

1. The Department investigated the allegation: Staff did not properly notify resident's responsible party of rate increase. LPA conducted interviews and reviewed records. Admission agreement stated there would be a certain amount of time allowed before increases took place. The facility did not follow the allowed time with proper written notice according to admission agreement.
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: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
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-20230807083425
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: 10/09/2023
NARRATIVE
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1. The Department investigated the allegation: Staff did not allow resident’s responsible party to participate in decision making regarding the care and services provided to the resident. LPA conducted interviews and reviewed records. Facility did not follow the admission agreement which stated there would be a certain amount of time allowed before changes to resident's care took place. The facility did not follow the admission agreement with proper written notice given to reporting party.

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 & HSC 1569.655 are being cited on the attached LIC 9099D

Exit interview was conducted and a copy of this report LIC909 , LIC9099D, and appeal rights were given to RCD Kimberly Jones.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20230807083425
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: 10/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2023
Section Cited
HSC
1569.655
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§1569.655 Increase in fee rates for elderly residents; 60 days’ written notice stating amount of and reasons for increase; application of section
(a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident. This subdivision shall not apply to optional services that are provided by individuals, professionals, or organizations under a separate fee-for-service arrangement with residents.
This requirement is not met as evidenced by:
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ED will continue to notify promptly to notify of any increases. Explaination will be sent to LPA.
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Based on observation, interview, & record review the licensee failed to give responsible party the proper 60-days notice in writing of fee increase.
This poses a potential health, safety, or personal rights risk to residents in care.
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Type B
10/16/2023
Section Cited
CCR
87507(f)
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87507 Admission Agreements
(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.
This requirement is not met as evidenced by:
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ED will clarify and confirm with legal POA to note primary contact. Will document elder mark of changes in sysytem. Email explaining
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Based on observation, interview, & record review the licensee failed to follow the notice agreement listed in the admission agreement when making changes to resident in care.
This poses a potential health, safety, or personal rights risk to residents in care
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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: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3