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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 207209043
Report Date: 07/15/2024
Date Signed: 07/28/2024 11:37:30 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
03/04/2024 and conducted by Evaluator Brianna Miranda
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240304133818
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: 87DATE:
07/15/2024
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Executive Director- Kelly ReynoldsTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff did not report incidents involving resident as required.
INVESTIGATION FINDINGS:
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On 7/15/24 Licensing Program Analysts (LPAs) B. Miranda & M. Vega arrived at the facility unannounced to deliver the finding for the allegation(s) listed above. LPA introduced herself and explained the reason for the visit. Executive Director Kelly Reynolds was contacted and met with LPAs.

1. The Department investigated the allegation: Staff did not report incidents involving resident as required. LPA conducted interviews and reviewed records. LPA was informed verbal contact was made with responsible party of R1. A timely incident report was sent to the Dept. Both responsible party and the Dept must be notified of the incident in writing within 7 days.
Based on LPAs observations, interviews, & record reviews which were conducted, 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 conducted and a copy of this report LIC9099, LIC9099D, and appeal rights were provided to Executive Director Kelly Reynolds.

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: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
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 2
Control Number 24-AS-20240304133818
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: 07/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2024
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
This requirement is not met as evidenced by:
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Executive Director Kelly Reynolds stated a document has been created to notify responsible party in writing. Copy will be provide to LPA.
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Based on observation, interview, & record review the licensee did not comply with the regulations listed above. Responsible party was notified verbally and not in writing.
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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: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
LIC9099 (FAS) - (06/04)
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