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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 207209043
Report Date: 02/18/2022
Date Signed: 02/22/2022 07:45:22 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
10/05/2021 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20211005112928
FACILITY NAME:CEDAR CREEK SENIOR LIVINGFACILITY NUMBER:
207209043
ADMINISTRATOR:JACKSON, SHAWNIEEFACILITY TYPE:
740
ADDRESS:500 N. WESTBERRY BLVD.TELEPHONE:
(559) 673-2345
CITY:MADERASTATE: CAZIP CODE:
93637
CAPACITY:162CENSUS: 80DATE:
02/18/2022
UNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Executive Director, Shawnie Jackson TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff are mismanaging resident’s medications.
Care and supervision is not being provided to residents while in care.
Facility had inadequate diapering supplies.
Facility has a rodent infestation.
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 allegations. 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.

During the investigation, LPA reviewed pest control records, medication records, staffing schedules, facility procedures and conducted interviews with staff, residents, and Executive Director. Based on the information received, the Department has found that the complaint was unfounded, meaning that the allegations are false, and/or is without reasonable basis.

No deficiencies cited on today's visit.


Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (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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