207209043-2-22-2022-24-AS-MHON-CBYNCH-20220225092045

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 207209043
Report Date: 02/18/2022
Date Signed: 02/22/2022 07:43:57 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/24/2021 and conducted by Evaluator Lisa Salazar

COMPLAINT CONTROL NUMBER: 24-AS-20210924163703

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: 80	DATE:	02/18/2022
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Executive Director, Shawnie Jackson		TIME COMPLETED:	01:11 PM

ALLEGATION(S):

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Resident fell multiple times while in care as the result of neglect, sustaining a fracture and hematoma.

INVESTIGATION FINDINGS:

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On 02/18/22, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to deliver findings on the above complaint allegation. LPA was greeted by front desk staff, stated the purpose of the visit, and was allowed entry into the facility. COVID precautionary measures were taken prior to LPA entering the facility.

The Department has investigated the above allegation. Through interviews and records review that were conducted, it was documented that Resident R1’s health began to decline. R1 was admitted to Hospice on 09/21/21 and moved to the “Generations” Memory Care unit. It was documented that R1 had been non-compliant in using their walker for ambulation. The facility responded immediately, called 911 and sought medical treatment for R1.

Although the allegation may have happened, there is not a preponderance of evident to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and copy of report was left with Executive Director. No Deficiencies cited on today’s visit.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa Salazar	TELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022

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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