207209043-11-22-2023-24-AS-BCHN-CZY2RB-20240129163715

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 207209043
Report Date: 10/09/2023
Date Signed: 11/22/2023 04:04:00 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
06/26/2023 and conducted by Evaluator Brianna Miranda

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20230626113948

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:	DATE:	10/09/2023
		UNANNOUNCED	TIME BEGAN:	09:27 AM
MET WITH:	Resident Care Director Kimberly Jones		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility is in financial distress.
Medication was accessible to residents in care.
Staff do not ensure kitchen is clean.

INVESTIGATION FINDINGS:

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On 10/9/2023 Licensing Program Analyst B. Miranda arrived to 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: Facility is in financial distress. On 7/5/23 LPA interviewed various staff members and documentation was reviewed showing due to non-payments vendors services were stopped and or notices were issued informing utilizes were going to be turned off. The Department was not informed of the financial distress of the facility.

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: 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)

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Control Number 24-AS-20230626113948

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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2. The Department investigated the allegation: Medication was accessible to residents in care. LPA interviewed staff who stated there was an incident where medication from one resident was left in another resident’s room unattended. This incident occurred in the Generations area where there are dementia residents. No documentation was maintained regarding the situation.

3. The Department investigated the allegation: Staff do not ensure kitchen is clean. The facility was previously cited for facility is dirty on 7/5/23. Please reference complaint # 24-AS-20230306123828 to view citing. The above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, and was previously cited. The kitchen was noted in this complaint.

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

Two citations were issued today for the three allegations listed above since one allegation was previously cited on 7/5/23 it was not cited again today.

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

This report has been amended. A copy of the amended report LIC809 was provided to Kelly Reynolds.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 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)

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Control Number 24-AS-20230626113948

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 A 10/10/2023 Section Cited CCR 87213	1 2 3 4 5 6 7	87213 Finances The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents; shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency. Such request shall explain the need for disclosure. The licensing agency reserves the right to reject any financial report and to request additional information or examination including interim financial statements. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	LPA met with Business Office Director who provided verifiation of payment for outstanding bills.
	8 9 10 11 12 13 14	Based on observation, interview, & record review the licensee failed to maintain finances due to unpaid bills which stopped services from vendors and received potential shut-off notices from utility company. This poses an immediate health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14
Type A 10/10/2023 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility had staff inservice regarding medication. RCD will provide verficiation to LPA.
	8 9 10 11 12 13 14	Based on observation, interview, & record review the licensee failed to keep medication inaccessible to residents in care. This poses an immediate health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14

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: 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)

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