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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 207209043
Report Date: 12/17/2021
Date Signed: 04/25/2022 01:54:41 PM


Document Has Been Signed on 04/25/2022 01:54 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



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: 87DATE:
12/17/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:02 PM
MET WITH:Lead Concierge, Debra SanchezTIME COMPLETED:
04:20 PM
NARRATIVE
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On 12/17/21, Licensing Program Analysts (LPA's) L. Salazar and M. Garza arrived at the facility unannounced to conduct the required 10 day site inspection for complaint allegations.

COVID precautionary measures were taken at the point of entry. LPA met with Lead Concierge, Debra Sanchez and stated the purpose of the visit. Executive Director, Shawnie Jackson has left for the day but has given the above staff authorization via telephone to sign reports.

LPAs' toured the facility. LPAs' observed a furniture blocking 2 out of the 4 exit doors located in the Generations (Memory Care Unit) that are identified as evacuation exits in a case of emergency.

LPAs' observed uncompleted construction in the Lobby of the facility and also resident's hallway next to the lobby.

In accordance with Title 22, California Code of Regulations , the following deficiencies are being cited based on LPAs observations. See LIC 809D. All violations that, if not corrected, will have a direct immediate and/or potential risk to the health, safety or personal rights of clients in care.

Exit interview was conducted with Debra Sanchez. A copy of the 809, 809-D and appeal rights will be provided to Executive Director via email by next business day.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2021
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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Document Has Been Signed on 04/25/2022 01:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: CEDAR CREEK SENIOR LIVING
FACILITY NUMBER: 207209043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2021
Section Cited

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Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by LPA's observations and pictures of furniture intentionally blocking the exit doors in the Gernerations (memory care unit).
Type B
12/31/2021
Section Cited

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87303 Maintenance and Operation
(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by LPA's observations of facility lobby and hallway to resident's room being in disrepair and under incomplete construction at the base of the walls.

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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: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2021
LIC809 (FAS) - (06/04)
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