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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 207209043
Report Date: 08/05/2026
Date Signed: 08/05/2026 05:42:28 PM

Document Has Been Signed on 08/05/2026 05:42 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:CEDAR CREEK SENIOR LIVINGFACILITY NUMBER:
207209043
ADMINISTRATOR/
DIRECTOR:		ROBERT HUNTLEYFACILITY TYPE:
740
ADDRESS:500 N. WESTBERRY BLVD.TELEPHONE:
(559) 673-2345
CITY:MADERASTATE: CAZIP CODE:
93637
CAPACITY: 162CENSUS: 114DATE:
08/05/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:33 AM
MET WITH:Lupe FierrosTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) K. Brown and M. Medina arrived unannounced to conduct the Annual Inspection. LPAs met with and explained the reason for the visit with Health Services Director (HSD) Lupe Fierros

During this visit, LPA Brown toured the facility with HSD including Independent Living, Assisted Living and Memory Care. Resident apartments and common areas were clean, in good repair containing required furnishings and lighting. LPA observed required items in bathrooms which were clean with hot water measuring between 113-115 degrees. LPA observed hygiene items, paper products, towels, extra bedding, and linens which were available for use in all areas. The kitchen was clean, containing necessary cooking items and appliances. LPA observed required food supply, including emergency food. There is a medication room located in Memory Care and in Assisted Living. Medications are centrally stored and distributed by Med Techs. Doors and passageways are unobstructed throughout the facility including outdoors.

LPA walked outside to find the grounds well-kept with patios, walkways and seating areas. Delayed Egress was in working order from Memory Care. Fire extinguishers were 1/8/26 by Johnson Controls. The Fire sprinkler system inspection was conducted 6/23/26. During this visit, LPAs conducted resident and staff file reviews including a medication audit. Fire and Emergency Drills are up to date.



LPAs observed the following deficiencies during today’s inspection:
-Medications and Cleaning supplies were accessible in resident apartments
-Employee and Resident files were incomplete and not up to date
-An oven in Memory Care is accessible to residents and needs a protective mechanism to prevent access
-The facility does not have a designated Administrator and has not notified CCLD of the vacancy

SEE LIC809-C FOR CONTINUATION OF THIS REPORT
Shawna Doucette
Katie Brown
DATE: 08/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 6
Document Has Been Signed on 08/05/2026 05:42 PM - It Cannot Be Edited


Created By: Katie Brown On 08/05/2026 at 04:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CEDAR CREEK SENIOR LIVING
FACILITY NUMBER: 207209043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(e)(1)(A)
Personal Accommodations and Services
(e) The licensee shall supervise residents as needed and as determined by the resident's appraisal pursuant to Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, when residents are in proximity to or when there is use of the following items: (1) Ranges, ovens, heaters, fireplaces, wood stoves, inserts, and other heating devices. (A) Heating devices shall have protective mechanisms or other measures to prevent access to the device, or to make it inoperable when not in use, in order to reduce the risk of burns or fire.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed a accessable functioning oven in Memory Care that does not have a cover or prevent acess to the device. There is nothing in place to prevent a resident from burns or fire.
POC Due Date: 09/07/2026
Plan of Correction
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HSD has agreed to submit proof of correction (picture or receipt) by poc date.
Type B
Section Cited
HSC
1569.618(a)
Other Provisions
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. The facility has not notified CCLD of the absence of a qualified Administrator for more than 30 days.
POC Due Date: 08/07/2026
Plan of Correction
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HSD has agreed to submit notification to CCLD of the designated facility manager until a Administrator of record is hired.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Katie Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/05/2026 05:42 PM - It Cannot Be Edited


Created By: Katie Brown On 08/05/2026 at 04:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CEDAR CREEK SENIOR LIVING
FACILITY NUMBER: 207209043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care. LPA observed cleaning solutions and accessible medications in apartments 127 and 105. Both residents Physicians reports state they cannot have access to these items.
POC Due Date: 08/06/2026
Plan of Correction
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HSD has agreed to submit a written statement which will include the facility plan to remove all identified items such as medications and cleaning supplies no later than 8/11/26. The statement will be submitted via fax to CCL by poc date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Katie Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2026


LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: CEDAR CREEK SENIOR LIVING
FACILITY NUMBER: 207209043
VISIT DATE: 08/05/2026
NARRATIVE
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Annual - Page 2

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D

An exit interview was conducted, a Plan of Correction was developed with HSD and a copy of this report was provided.

LPA requested the following updated forms faxed to CCLD by 8/7/2026 - Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Client Roster (LIC 9020) and Proof of current Liability Coverage.
NAME OF LICENSING PROGRAM MANAGER: Shawna Doucette
NAME OF LICENSING PROGRAM ANALYST: Katie Brown
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2026
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 08/05/2026 05:42 PM - It Cannot Be Edited


Created By: Katie Brown On 08/05/2026 at 04:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CEDAR CREEK SENIOR LIVING
FACILITY NUMBER: 207209043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, hich poses/posed a potential health, safety or personal rights risk to persons in care. Record review conducted of 8 employee files which were found to be incomplete, not containing all required documents or current records.
POC Due Date: 09/07/2026
Plan of Correction
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HSD has agreed to conduct an audit of resident files. Proof of completion will be sent to CCL by poc date.
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. Record review conducted of resident files which were found to be incomplete, not containing all required documents or current records.
POC Due Date: 09/07/2026
Plan of Correction
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HSD has agreed to conduct an audit of employeet files. Proof of completion will be sent to CCL by poc date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Katie Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2026


LIC809 (FAS) - (06/04)
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