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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 207209043
Report Date: 02/23/2023
Date Signed: 02/27/2023 04:09:25 PM


Document Has Been Signed on 02/27/2023 04:09 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:JACKSON, SHAWNIEEFACILITY TYPE:
740
ADDRESS:500 N. WESTBERRY BLVD.TELEPHONE:
(559) 673-2345
CITY:MADERASTATE: CAZIP CODE:
93637
CAPACITY:162CENSUS: 76DATE:
02/23/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Shawnee Jackson- Executive directorTIME COMPLETED:
10:00 AM
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On 02/23/23, Licensing Program Analyst (LPA) V Gorban conducted an unannounced Case Management visit. LPA introduced self and was allowed entrance by staff. LPA met with Executive Director (ED) Shawnee Jackson and stated reason for visit.

LPA arrived at the facility to conduct case management visit to relay information about Immediate Exclusion order for Staff (S1). LPA verified with ED that S1 has not worked in facility since S1 was not completed physical examination. Administrator responded that S1 has not been with the facility or worked for Cedar Creek. Executive Director was advised an exclusion has been ordered and issued by the Department and provided an exclusion order document for the facility stated above. Per ED S1 was never associated with the facility personnel and report provided by LPA. LPA also provided the ED with a copy of the Decision and Order.

No deficiencies sited during this Case Management visit. An exit interview was conducted, and report signed on-site, and a copy of report will be provided for the facility records.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
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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