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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 207209043
Report Date: 09/09/2024
Date Signed: 09/09/2024 04:10:50 PM


Document Has Been Signed on 09/09/2024 04:10 PM - 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: DATE:
09/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:04 PM
MET WITH:TIME COMPLETED:
04:30 PM
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On 9/9/2024 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct a case management visit to follow-up on incident reports received. LPA met with Business Office Director (BOD) Deborah Sanchez.

Maintenance Director (MD) Jeff Hicks provided a copy of the invoice from the boiler being serviced. The boiler went out on 8/10/24 and was fixed on 8/22/24. LPA asked what plan was put into place, BOD stated there were empty rooms that were offered to the residents. BOD stated certain areas upstairs were effected by the boiler going out. LPA spoke with R1 who stated they were without water for a bit but it is fixed and everything is alright. LPA asked MD & BOD why it took so long to get the boiler fixed, MD stated the part was obsolete and had to be ordered. MD also stated the part was shipped from the East Coast and during that time there were weather issues which could have caused the delay. MD stated they are ordering additional parts in case the part goes out in other broilers.

LPA spoke with Health & Wellness Director (HWD) Lupe Fierros regarding incident reports the Dept received for R2, R3, and R4.

R2 passed away on 8/30/24 at the hospital. R2 was diagnosed with Type 2 Diabetes but was managed by diet. LPA did not find any deficiency with R2's care.

R3 was sent to the hospital on 8/28/24. LPA interviewed R3 who stated they fell in the kitchen. LPA asked how long it took for R3 to go to the hospital but R3 was not able to give an answer. Cause of fall is unknown.

R4 is currently at the hospital. LPA spoke with HWD who stated R4 has a blood sugar monitor on their arm and it is changed every 14 days by R4's sister. R4's last Physician Report was completed on 5/24/24 which states R4 cannot manage medications, cannot administer their own medication, cannot administer own injections, and cannot perform own glucose testing.
No deficiencies were found during this visit and no citations were issued.
Exit interview was conducted and a copy of this report was provided to Health & Wellness Director (HWD) Lupe Fierros.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024
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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