Inspection Reports for Cogir of Cedar Creek
500 N Westberry Blvd, Madera, CA 93637, United States, CA, 93637
Back to Facility ProfileInspection Report Summary
Most inspections at Cedar Creek Senior Living Facility found deficiencies related primarily to food safety, kitchen cleanliness, medication management, resident supervision, and documentation, with several substantiated complaints about inadequate staffing and failure to meet reporting requirements. The facility faced some serious issues including a staff member taking unauthorized photos of a resident in April 2025, which led to termination and a citation, and financial distress cited in late 2023 and early 2024 posing a risk to residents. Several complaint investigations were unsubstantiated, indicating that many concerns raised were not confirmed. The most recent report from August 14, 2025, found multiple deficiencies in kitchen sanitation and chemical storage but no severe enforcement actions or fines were listed. While the facility has ongoing challenges in environment/safety and resident care areas, the record shows some improvement as the August 11, 2025 inspection was clean and free of deficiencies.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
11.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
190% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
60% occupied
Based on a August 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 97
Capacity: 162
Deficiencies: 4
Date: Aug 14, 2025
Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate compliance with licensing requirements at Cedar Creek Senior Living Facility.
Findings
The inspection found multiple deficiencies including unclean kitchen and dining areas, evidence of bugs in the Memory Care kitchen, improperly stored food items without labeling, leaking sink plumbing, and hazardous cleaning chemicals stored in unlocked cabinets. Fire and carbon monoxide detectors were found to be in working order. Citations were issued per Title 22.
Deficiencies (4)
Cleaning chemicals and Sterno-burner fuel were stored in an unlocked cabinet in the main dining room.
Dining room drawer needed repair, water puddle by ice machine, dirty cabinets, appliances and walls in Memory Care, trash in cabinets, dirty refrigerator, leaky sink plumbing, and kitchen needed decluttering and degreasing.
Packages of food were left open and exposed in the pantry and refrigerator without dates or labeling.
Dead beetle observed inside the Memory Care kitchen cabinet.
Report Facts
Capacity: 162
Census: 97
Plan of Correction Due Dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Huntley | Executive Director | Met with Licensing Program Analyst during inspection and received report |
| Daiquiri Boyd | Licensing Program Analyst | Conducted the inspection and signed the report |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 97
Capacity: 162
Deficiencies: 0
Date: Aug 11, 2025
Visit Reason
The inspection was a required unannounced Annual Inspection visit conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was observed to be clean, clutter free, and odor free. Water temperatures in various units were within acceptable ranges. Staff and resident files were complete and up to date. No citations or deficiencies were noted during this visit. The annual inspection was not completed at this time and will be completed at a later date.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Huntley | Executive Director | Met with during inspection and assisted in the inspection. |
| Daiquiri Boyd | Licensing Program Analyst | Conducted the inspection visit. |
| Kimberly Eldridge | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 162
Deficiencies: 1
Date: Apr 17, 2025
Visit Reason
The visit was an unannounced Case Management inspection relating to an Incident Report received on 2025-04-11 regarding a resident (R1) who was photographed without permission while using the restroom.
Complaint Details
The visit was triggered by a complaint involving unauthorized photography of a resident by staff member S1. The complaint was substantiated as S1 was terminated following the incident and police investigation.
Findings
The investigation found that staff member S1 took a photograph of R1 without consent and shared it with a former employee. The police investigated but did not press charges. S1 was placed on administrative leave and then terminated. A citation will be issued for this violation.
Deficiencies (1)
R1 was photographed while using the restroom by caregiver S1. The picture was subsequently shared with a former employee. This poses an immediate risk to the health and safety of residents in care.
Report Facts
Capacity: 162
Census: 74
Plan of Correction Due Date: Apr 25, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachel A Bruce | Licensing Program Analyst | Conducted the inspection and signed the report |
| Kelly Reynolds | Administrator | Met with Licensing Program Analyst during inspection |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 74
Capacity: 162
Deficiencies: 0
Date: Apr 8, 2025
Visit Reason
An unannounced Case Management visit was conducted to relay information about an Immediate Exclusion order for a staff member (S1).
Findings
No deficiencies were cited during this Case Management visit. The staff member subject to the exclusion order was verified to have never worked at or been associated with the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Reynolds | Administrator | Met with Licensing Program Analysts during the visit and verified staff exclusion status. |
| Rachel Bruce | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Jimmy Duarte | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
Inspection Report
Census: 79
Capacity: 162
Deficiencies: 0
Date: Mar 13, 2025
Visit Reason
The visit was an unannounced case management incident inspection conducted due to an incident report received in January 2025 regarding a resident's foot ulcer and subsequent hospitalization.
Findings
The Licensing Program Analyst found that the resident had an existing foot wound upon admission and that the facility had appropriately reported the incident. No citations were issued during the visit.
Report Facts
Resident admission date: Jan 10, 2025
Hospitalization date: Jan 19, 2025
Resident death date: Feb 9, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Reynolds | Administrator | Met with Licensing Program Analyst during the visit |
| B. Miranda | Licensing Program Analyst | Conducted the case management visit |
| Rachel A Bruce | Licensing Program Analyst | Named as Licensing Program Analyst on report |
Inspection Report
Census: 87
Capacity: 162
Deficiencies: 1
Date: Nov 7, 2024
Visit Reason
An unannounced case management visit was conducted to review compliance with reporting requirements and other regulatory obligations.
Findings
The facility was found deficient for failing to submit a death report for resident R2 within the required 7-day timeframe, posing a potential health, safety, or personal rights risk to residents.
Deficiencies (1)
Failure to submit a written death report for resident R2 within seven days of the occurrence as required by Title 22, Section 87211 Reporting Requirements.
Report Facts
Deficiency Plan of Correction Due Date: Nov 22, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Reynolds | Administrator | Met with Licensing Program Analyst during the visit and named in findings related to reporting deficiency |
| Brianna Miranda | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Brenda Chan | Licensing Program Manager | Supervisor of the Licensing Program Analyst and named in the report |
Inspection Report
Capacity: 162
Deficiencies: 0
Date: Sep 9, 2024
Visit Reason
The visit was an unannounced case management follow-up on incident reports received by the facility.
Findings
No deficiencies were found during this visit and no citations were issued. The visit included review of incidents involving residents and discussions with facility staff regarding a boiler repair and resident care.
Report Facts
Capacity: 162
Boiler outage duration (days): 12
Incident dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Sanchez | Business Office Director | Met with Licensing Program Analyst during visit |
| Jeff Hicks | Maintenance Director | Provided invoice and information about boiler repair |
| Lupe Fierros | Health & Wellness Director | Provided information regarding resident incidents and care |
| Brianna Miranda | Licensing Program Analyst | Conducted the inspection visit |
| Brenda Chan | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 87
Capacity: 162
Deficiencies: 11
Date: Jul 22, 2024
Visit Reason
The visit was an unannounced continuation of the annual inspection to evaluate compliance with licensing requirements at Cedar Creek Senior Living Facility.
Findings
Multiple deficiencies were observed including unsafe storage of cleaning supplies and scissors accessible to residents, improper food storage and sanitation issues in the kitchen, locked exit routes obstructed by chairs, and waste bags left outside resident rooms. The facility was otherwise odor free during the tour.
Deficiencies (11)
Waste bag with gloves left outside of resident's room on the second floor
Broken glass jar and cleaning supplies in the card room left unlocked and accessible to residents
Scissors left unlocked and accessible to residents in the coffee/tea area near entrance
Kitchen has meat defrosting with blood leaking from package and not properly stored
Freezer has multiple items opened and not stored/closed properly, food items not labeled
One strawberry pack was rotting
Puddle of water next to the ice machine, mildew inside the ice machine
Kitchen floors near the stove have debris and oil
Window sills in the dining area have debris
Cabinets in various areas are unclean and have debris
One listed exit route is locked and the outside door is obstructed by chairs
Report Facts
Capacity: 162
Census: 87
Plan of Correction Due Dates: Jul 23, 2024
Plan of Correction Due Dates: Aug 2, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Reynolds | Executive Director | Met during inspection and named in relation to findings and plans of correction |
| Brianna Miranda | Licensing Program Analyst | Conducted inspection and signed report |
| Brenda Chan | Licensing Program Manager | Supervisor named in report |
Inspection Report
Annual Inspection
Census: 87
Capacity: 162
Deficiencies: 0
Date: Jul 15, 2024
Visit Reason
Licensing Program Analysts conducted a required unannounced Annual Inspection visit to evaluate the facility's compliance with regulations.
Findings
The facility was observed to be clean, clutter free, and odor free. Infection control and disaster plans were current and complete. Staff and resident files were reviewed and found to be complete and up to date. No citations were issued during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Reynolds | Executive Director | Met with Licensing Program Analysts during the inspection visit. |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 162
Deficiencies: 1
Date: Jul 15, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2024-03-04 alleging that staff did not report incidents involving a resident as required.
Complaint Details
The complaint was substantiated based on interviews, observations, and record reviews. The allegation was that staff did not report incidents involving a resident as required. The preponderance of evidence standard was met confirming the violation.
Findings
The investigation found the allegation substantiated. The licensee did not comply with reporting requirements as the responsible party was notified verbally but not in writing within the required seven days.
Deficiencies (1)
Failure to submit a written incident report to the licensing agency and responsible party within seven days as required by CCR 87211(a)(1).
Report Facts
Census: 87
Total Capacity: 162
Plan of Correction Due Date: Jul 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Reynolds | Executive Director | Met with Licensing Program Analysts and named in findings regarding failure to notify responsible party in writing |
| Brianna Miranda | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 162
Deficiencies: 0
Date: Jul 15, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-03-04 regarding staff failing to prevent a resident from being assaulted by another resident and failing to prevent resident exploitation.
Complaint Details
The complaint involved allegations that staff did not prevent a resident from being assaulted by another resident and did not prevent resident exploitation. The investigation was unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Interviews and record reviews indicated the assault was an isolated event and no updated power of attorney for medical was found, but paperwork remained the same. The allegations were determined to be unsubstantiated.
Report Facts
Facility capacity: 162
Resident census: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Reynolds | Executive Director | Met with Licensing Program Analysts during the investigation and received report |
| Brianna Miranda | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 162
Deficiencies: 0
Date: Feb 7, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-01-25 regarding multiple allegations about facility conditions and operations.
Complaint Details
The complaint included allegations of filthy ventilation returns, poor kitchen nutrition, canceled activities, unsanitized tables, kitchen staff not wearing hair nets or masks, and lack of certified drivers in December allowing staff to drive commercial vehicles. The investigation found no preponderance of evidence to substantiate these allegations; therefore, the complaint was unsubstantiated.
Findings
After conducting interviews, observations, and record reviews, the Licensing Program Analyst found insufficient evidence to substantiate the allegations. The ventilation returns were not dirty, kitchen nutrition was adequate, activities were generally available, tables were sanitized, kitchen staff complied with applicable regulations, and although there were no certified drivers in December, the vans were being used appropriately.
Report Facts
Facility capacity: 162
Census: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brianna Miranda | Licensing Program Analyst | Conducted the complaint investigation |
| Kelly Reynolds | Executive Director | Met with Licensing Program Analyst during investigation |
| Kimberly Elderidge | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 162
Deficiencies: 0
Date: Feb 7, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2023-10-09 regarding the facility being in disrepair and not providing a safe environment for residents.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included the facility being in disrepair and not providing a safe environment. After interviews, observations, and record reviews, there was not enough evidence to support the allegations.
Findings
The investigation found no evidence to substantiate the allegations. The facility was not observed to be in disrepair, and interviews with staff and residents indicated the facility managed the situation caused by a power outage due to an accident. There was insufficient evidence to prove the alleged violations occurred, resulting in an unsubstantiated finding.
Report Facts
Capacity: 162
Census: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brianna Miranda | Licensing Program Analyst | Conducted the complaint investigation |
| Kelly Reynolds | Executive Director | Met with Licensing Program Analyst during the investigation |
| Kimberly Elderidge | Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 162
Deficiencies: 0
Date: Feb 7, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2023-10-09 regarding inadequate supervision, loss of electricity, inadequate food service, resident council management, and lack of activities for residents.
Complaint Details
The complaint investigation was unsubstantiated as there was not a preponderance of evidence to prove the alleged violations occurred. Allegations included inadequate supervision resulting in residents wandering, facility left without electricity, inadequate food service, resident council run by staff, and lack of activities.
Findings
After interviews, observations, and record reviews, the Licensing Program Analyst found insufficient evidence to substantiate the allegations. The facility was found to have adequate supervision, food service, and activities, and the electricity outage was due to circumstances beyond the facility's control.
Report Facts
Capacity: 162
Census: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brianna Miranda | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kelly Reynolds | Executive Director | Met with Licensing Program Analyst during inspection |
| Kimberly Elderidge | Administrator | Met with Licensing Program Analyst during inspection |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 67
Capacity: 162
Deficiencies: 0
Date: Jan 25, 2024
Visit Reason
The visit occurred to collect original reports and provide amended reports due to the need to amend previous reports.
Findings
The Licensing Program Analyst collected the original reports and provided a copy of the amended reports to the Executive Director. An exit interview was conducted, and the process was completed without noted deficiencies.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Reynolds | Executive Director | Met with Licensing Program Analyst during report collection and amendment process. |
| Kimberly Eldridge | Administrator | Met with Licensing Program Analyst during report collection and amendment process. |
Inspection Report
Monitoring
Census: 74
Capacity: 162
Deficiencies: 1
Date: Jan 16, 2024
Visit Reason
The visit was an informal meeting conducted via teleconference to discuss the findings of a Solvency Audit initiated after a complaint alleging the facility was in financial distress.
Complaint Details
The Solvency Audit was initiated after a complaint received on 06/26/2023 alleging the facility was in financial distress.
Findings
The licensee failed to maintain a good financial position with insufficient and negative cash reserves from June 2022 to May 2023, lacking an adequate financial plan as required by law, posing an immediate health, safety, or personal rights risk to residents.
Deficiencies (1)
87205 Accountability of Licensee Governing Body: The licensee failed to maintain financial position with insufficient and negative cash reserves and lacked an adequate financial plan, posing immediate risk to residents.
Report Facts
Census: 74
Total Capacity: 162
Deficiency Count: 1
Plan of Correction Due Date: Jan 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Eldridge | Administrator | Named in relation to the informal meeting and exit interview |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager and supervisor of the audit |
| Brianna Miranda | Licensing Program Analyst | Named as Licensing Program Analyst and evaluator of the audit |
| Kelly Reynolds | Executive Director | Attendee at the informal meeting discussing management transition |
| Ben Levesque | Executive VP of Operations | Attendee at the informal meeting discussing financial and operational status |
Inspection Report
Census: 68
Capacity: 162
Deficiencies: 0
Date: Nov 30, 2023
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident report received regarding a 7-day shut off notice from PG&E dated 11/17/23.
Findings
The Licensing Program Analyst conducted a walk-around and verified no immediate danger was present. The facility had paid the outstanding amount on 11/28/23, and no citations or civil penalties were issued at the time of the visit.
Report Facts
7-day shut off notice due date: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Reynolds | Executive Director | Met with Licensing Program Analyst during the visit |
| Brianna Miranda | Licensing Program Analyst | Conducted the case management visit |
| Brenda Chan | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 72
Capacity: 162
Deficiencies: 12
Date: Nov 16, 2023
Visit Reason
The inspection was an unannounced annual case management continuation visit to complete the annual inspection originally started on 2023-07-27.
Findings
The facility was found to have multiple deficiencies including lack of current staff training and CPR/first aid certification, unsecured cleaning supplies accessible to residents, improper food handling and storage, outdated emergency contact information in resident charts, missing modifications on admission agreements, and cleanliness issues in various areas including the kitchen and common areas.
Deficiencies (12)
Cleaning supplies and scissors were not locked away and accessible to residents in the Generations area.
Facility was unable to provide current/valid First Aid/CPR cards for staff members.
Food was not properly stored and staff were not using gloves when handling food.
Meat was not properly stored in the refrigerator with other food.
Resident charts did not have current emergency contact information.
Facility did not have Plan of Operations on file at the facility.
Cabinets in the Madera Room and kitchen/cabinets in Generations needed cleaning.
Resident charts did not have current physician's report for residents with dementia.
No modifications to admission agreements were observed when rent increased or status changed.
Storage closet with cleaning supplies was not able to close properly.
Various kitchen areas were not cleaned, sanitized, and had debris buildup.
Facility was not able to provide a resident roster readily available in case of emergency during prior visit.
Report Facts
Capacity: 162
Census: 72
Deficiency count: 12
Plan of Correction Due Dates: Nov 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brianna Miranda | Licensing Program Analyst | Conducted the inspection and authored the report |
| Brenda Chan | Licensing Program Manager | Supervisor for the inspection |
| Kelly Metz | Executive Director | Facility representative during inspection |
Inspection Report
Complaint Investigation
Capacity: 162
Deficiencies: 2
Date: Oct 9, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 06/26/2023 regarding financial distress, medication accessibility to residents, and kitchen cleanliness at Cedar Creek Senior Living Facility.
Complaint Details
The complaint investigation was substantiated. Allegations included financial distress, medication accessibility to residents, and unclean kitchen. The facility was previously cited for kitchen cleanliness. The investigation found evidence supporting all allegations.
Findings
The investigation substantiated all three allegations: the facility was in financial distress with unpaid bills causing service interruptions; medication was accessible to residents in care, posing safety risks; and staff failed to ensure the kitchen was clean, a previously cited issue. Two citations were issued related to finances and medication storage.
Deficiencies (2)
Failure to maintain finances due to unpaid bills which stopped services from vendors and received potential shut-off notices from utility company.
Failure to keep medication inaccessible to residents in care.
Report Facts
Facility capacity: 162
Deficiency citations: 2
Plan of Correction due date: Oct 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Jones | Resident Care Director | Met with Licensing Program Analyst during investigation and named in findings |
| Brianna Miranda | Licensing Program Analyst | Conducted the complaint investigation visit |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 162
Deficiencies: 0
Date: Oct 9, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2023-06-26 regarding facility disrepair, unsanitary conditions, and failure to provide a comfortable environment for residents.
Complaint Details
The complaint was unsubstantiated after investigation. Allegations included facility disrepair, unsanitary conditions, and staff failing to provide a comfortable environment. Multiple complaints were investigated simultaneously with no violations found.
Findings
The investigation found no substantiated evidence to support the allegations. The facility was not found to be in disrepair, unsanitary, nor were residents found to be uncomfortable during the visit and prior observations.
Report Facts
Capacity: 162
Census: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Jones | Resident Care Director | Met with Licensing Program Analyst during the investigation |
| Brianna Miranda | Licensing Program Analyst | Conducted the complaint investigation visit |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Capacity: 162
Deficiencies: 0
Date: Oct 9, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2023-06-26 alleging that staff did not make all licensing reports issued by CCL accessible to residents.
Complaint Details
The complaint alleged that staff did not make all licensing reports issued by CCL accessible to residents. The allegation was investigated and found to be unsubstantiated.
Findings
The investigation found that staff had a binder with licensing reports and documents available upon request. Although the allegation may have been valid, there was not a preponderance of evidence to prove the violation occurred, and the allegation was unsubstantiated.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Jones | Resident Care Director | Met with Licensing Program Analyst during the investigation and was given a copy of the report. |
| Brianna Miranda | Licensing Program Analyst | Conducted the complaint investigation visit. |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 162
Deficiencies: 2
Date: Oct 9, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-08-07 regarding allegations about staff not properly notifying the resident's responsible party of a rate increase and not allowing the responsible party to participate in decision-making regarding care and services.
Complaint Details
The complaint was substantiated based on interviews, observations, and record reviews. The allegations involved failure to notify the responsible party of rate increases and failure to allow participation in care decisions. The substantiation was based on the preponderance of evidence standard.
Findings
The investigation substantiated that the facility failed to provide proper 60-day written notice of fee increases to the resident's responsible party and did not follow the admission agreement regarding notification and participation in care decisions. These failures pose potential risks to residents' health, safety, or personal rights.
Deficiencies (2)
Failed to give responsible party the proper 60-days written notice of fee increase as required by HSC 1569.655.
Failed to comply with admission agreement terms regarding notification and participation in care decisions as required by CCR 87507(f).
Report Facts
Capacity: 162
Census: 68
Plan of Correction Due Date: Oct 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Jones | Resident Care Director | Met with Licensing Program Analyst during investigation and named in findings |
| Brianna Miranda | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 162
Deficiencies: 0
Date: Aug 24, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2023-05-01 alleging inadequate resident showering, food service, and prolonged soiling of residents.
Complaint Details
The complaint alleged that staff did not ensure residents' showering needs were met, did not provide adequate food service, and left residents soiled for extended periods. The allegations were found unsubstantiated.
Findings
The investigation found the allegations to be unsubstantiated based on interviews and records review, with no preponderance of evidence to prove the alleged violations occurred.
Report Facts
Facility capacity: 162
Census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Jones | Resident Care Director | Met with Licensing Program Analyst during complaint investigation |
| Brianna Miranda | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 162
Deficiencies: 4
Date: Aug 24, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-05-01 regarding allegations of inadequate care including failure to clean a resident's pressure injury, delayed response to call buttons, and inadequate staffing to meet residents' needs.
Complaint Details
The complaint investigation was substantiated based on interviews, observations, and record reviews. Allegations included failure to clean a resident's pressure injury, delayed response to call buttons, and inadequate staffing. The facility was found to be short staffed and unable to meet resident needs adequately.
Findings
The investigation substantiated all three allegations: the facility failed to ensure proper care for a resident's pressure injury, had delayed responses to resident call buttons due to staffing shortages, and lacked adequate staffing to meet resident needs. Multiple regulatory violations were cited related to home health care coordination, catheter care, and resident personal rights.
Deficiencies (4)
Failure to provide supporting care and supervision needed to meet the needs of the resident receiving home health care; no completed health plan on file.
Failure to ensure proper care for indwelling urinary catheter including documentation and staff instruction.
Inadequate staffing to care for resident and failure to send resident to hospital when needed.
Failure to respond timely to resident's call pendant, posing potential health, safety, or personal rights risk.
Report Facts
Capacity: 162
Census: 65
Call response time: 18
Plan of Correction Due Dates: Aug 25, 2023
Plan of Correction Due Dates: Aug 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Jones | Resident Care Director | Met with Licensing Program Analyst during investigation and named in findings |
| Brianna Miranda | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on report |
| Shawniee Jackson | Administrator | Facility Administrator named in report but not available during visit |
Inspection Report
Capacity: 162
Deficiencies: 1
Date: Aug 11, 2023
Visit Reason
The visit was an unannounced case management inspection conducted to follow up on an incident report regarding the death of a resident (R1) for which no death report had been submitted to the Department as required.
Findings
The facility failed to submit a required death report for resident R1 within the mandated timeframe, which is a citable deficiency under Title 22, Division 6, Chapter 8. Resident files must be retained for a minimum of three years following termination of service.
Deficiencies (1)
Failure to provide the Department with a death report for resident R1 within seven days of the occurrence as required by Title 22, Division 6, Chapter 8, regulation 87506 Resident Records.
Report Facts
Capacity: 162
Plan of Correction Due Date: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Jones | Resident Care Director | Met with Licensing Program Analyst during inspection and was provided with deficiency notices |
| Brianna Miranda | Licensing Program Analyst | Conducted the unannounced case management visit and signed the report |
| Brenda Chan | Licensing Program Manager | Supervisor of the Licensing Program Analyst and named in the report |
Inspection Report
Annual Inspection
Census: 62
Capacity: 162
Deficiencies: 0
Date: Jul 27, 2023
Visit Reason
The visit was an unannounced annual inspection conducted by the Licensing Program Analyst to evaluate the facility's compliance with regulatory standards.
Findings
The inspection included a tour of the facility, verification of fire extinguisher service dates, water temperature checks, and resident interviews. The facility lacked verification of carbon monoxide detector testing. Due to time constraints, the annual inspection was not completed and deficiencies will be issued later.
Report Facts
Water temperature: 113.7
Fire extinguisher last serviced date: Feb 21, 2023
Smoke detector last tested date: Nov 17, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Jones | Resident Care Director | Met with Licensing Program Analyst during inspection and exit interview |
| Brianna Miranda | Licensing Program Analyst | Conducted the annual inspection |
| Brenda Chan | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 162
Deficiencies: 5
Date: Jul 5, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2023-03-06 regarding staff non-compliance with Covid-19 masking protocols, food safety procedures, facility cleanliness, response times to resident requests, and medication administration.
Complaint Details
The complaint investigation was substantiated based on observations, interviews, and record reviews. The allegations included failure to follow Covid-19 masking protocols, food safety procedures, facility cleanliness, timely response to resident requests, and correct medication administration.
Findings
The investigation substantiated all allegations, finding staff not properly wearing masks, kitchen staff not following food safety protocols, facility areas being dirty, delayed responses to resident call pendants, and improper medication administration and documentation.
Deficiencies (5)
Staff not wearing gloves or hairnets during food preparation, violating food safety procedures.
Facility not clean and maintained, including dirty window sills, mold in ice machine, and dirty Madera room accessible to residents.
Resident medication logs not properly completed; medication not given or documented correctly.
Resident call pendant logs showed delays up to an hour in staff response to resident requests.
Staff not consistently wearing masks properly, including kitchen manager and maintenance personnel.
Report Facts
Capacity: 162
Census: 69
Deficiency count: 5
Plan of Correction Due Date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gaby Alvarado | Senior Director of Sales & Marketing | Met during inspection and exit interview |
| Brianna Miranda | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 162
Deficiencies: 0
Date: Jul 5, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-03-06 alleging that the facility is in disrepair.
Complaint Details
The complaint alleged that the facility was in disrepair. The allegation was investigated but found unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation included staff interviews and a facility tour. Some areas needed cleaning and repairs were ongoing in the Redwood Room. However, there was insufficient evidence to substantiate the allegation, so it was deemed unsubstantiated.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brianna Miranda | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Gaby Alvarado | Senior Director of Sales & Marketing | Met with Licensing Program Analyst during the investigation and received the report. |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 162
Deficiencies: 2
Date: Jul 5, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-03-29 regarding staff not safeguarding resident records and inadequate supervision to prevent residents from leaving the facility.
Complaint Details
The complaint investigation was substantiated based on observations, interviews, and record reviews. The allegations included failure to safeguard resident records and inadequate supervision preventing residents from leaving the facility. The preponderance of evidence standard was met, and citations were issued under California Code of Regulations, Title 22, Division 6 & Chapter 8.
Findings
The investigation substantiated that staff did not safeguard resident records as the medication room door was left unlocked, making records accessible. Additionally, staff failed to provide adequate supervision, allowing a memory care resident to leave the facility and enter the parking lot without staff awareness.
Deficiencies (2)
Facility personnel were insufficient in numbers and competence to meet resident needs, allowing a memory care resident to leave the facility unsupervised.
Resident records were not properly safeguarded as the medication room door was left unlocked, making confidential information accessible.
Report Facts
Capacity: 162
Census: 69
Plan of Correction Due Date: Jul 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawniee Jackson | Administrator | Interviewed regarding supervision and medication room door being left open |
| Gaby Alvarado | Senior Director of Sales & Marketing | Met with Licensing Program Analyst during inspection |
| Brianna Miranda | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 162
Deficiencies: 0
Date: Jul 5, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-03-29 regarding personnel records not being adequately maintained by staff.
Complaint Details
The complaint alleged that personnel records were not adequately maintained by staff. The allegation was investigated through staff interviews and review of personnel records, but was found unsubstantiated.
Findings
The investigation found that although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation was unsubstantiated.
Report Facts
Capacity: 162
Census: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gaby Alvarado | Senior Director of Sales & Marketing | Met with Licensing Program Analyst during the investigation and received a copy of the report |
| Brianna Miranda | Licensing Program Analyst | Conducted the complaint investigation visit |
| Brenda Chan | Licensing Program Manager | Named in the report header |
Inspection Report
Census: 62
Capacity: 162
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
The visit was an unannounced case management inspection regarding the facility administrator, specifically to verify the status of the certified administrator after the previous administrator left the facility.
Findings
The facility had not provided verification of a certified administrator at the time of the visit. The facility was informed that verification needed to be provided by the end of business day on 7/3/2023.
Report Facts
Days to provide verification: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawniee Jackson | Administrator | Named as the previous administrator who is no longer working at the facility. |
| Marilyn Couzens | Resident Care Director | Contacted during the inspection and received a copy of the report. |
| Brianna Miranda | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Brenda Chan | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 162
Deficiencies: 1
Date: Jun 14, 2023
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that facility staff did not properly manage a resident's medication.
Complaint Details
The complaint alleging improper management of a resident's medication was substantiated based on the preponderance of evidence standard.
Findings
The investigation substantiated the allegation after interviews, observations, and record reviews revealed incomplete Centrally Stored Medication logs and incorrect medication amounts in containers.
Deficiencies (1)
Failure to maintain a record of dosages of centrally stored medications as required by CCR 87465(a)(6), evidenced by incomplete medication logs and incorrect medication amounts in containers.
Report Facts
Capacity: 162
Census: 63
Deficiencies cited: 1
Plan of Correction Due Date: Jun 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brianna Miranda | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Marilyn Couzens | Resident Care Director | Met with Licensing Program Analyst during investigation and received report |
| Brenda Chan | Licensing Program Manager | Oversaw the licensing program and is named on the report |
| Shawniee Jackson | Administrator | Facility administrator named in the report |
Inspection Report
Capacity: 162
Deficiencies: 1
Date: Jun 14, 2023
Visit Reason
The visit was an unannounced case management inspection conducted by Licensing Program Analyst B. Miranda to review compliance and facility operations.
Findings
The inspection found that the Interim Administrator (S1) did not have proper clearance to work at the facility, resulting in a citation issued under Title 22, Division 6, Chapter 8.
Deficiencies (1)
Failure to obtain a California clearance or criminal record exemption for staff prior to working in the facility, specifically uncleared staff S1 was observed working without proper clearance.
Report Facts
Capacity: 162
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawniee Jackson | Administrator | Named as former administrator no longer at the facility |
| Marilyn Couzens | Resident Care Director | Met with Licensing Program Analyst during inspection |
| Brianna Miranda | Licensing Program Analyst | Conducted the inspection |
| Brenda Chan | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Census: 76
Capacity: 162
Deficiencies: 1
Date: Mar 10, 2023
Visit Reason
The visit was an unannounced Case Management inspection conducted in response to information received regarding a previous COVID-19 outbreak at the facility from November to December 2022.
Findings
The Licensing Program Analyst found discrepancies between the number of positive COVID-19 cases reported to the licensing agency and the facility's COVID-19 log, indicating underreporting. A citation was issued for failure to comply with reporting requirements under Title 22, Division 6, Chapter 8, Article 04.
Deficiencies (1)
Failure to comply with reporting requirements for epidemic outbreaks by not accurately reporting the number of positive COVID-19 cases to the licensing agency.
Report Facts
Positive COVID-19 cases: 33
Capacity: 162
Census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawniee Jackson | Administrator | Met with Licensing Program Analyst during the inspection |
| Brianna Miranda | Licensing Program Analyst | Conducted the inspection and authored the report |
| Brenda Chan | Licensing Program Manager | Supervisor of the Licensing Program Analyst |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 162
Deficiencies: 0
Date: Mar 7, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2022-10-11 regarding allegations of resident injuries from falls, medication mishandling, and overmedication.
Complaint Details
The complaint involved allegations that a resident sustained injuries from falls, staff mishandled a resident's medication, and staff overmedicated a resident. The allegations were found to be unsubstantiated.
Findings
The investigation included interviews and records review, and found no preponderance of evidence to substantiate the allegations. The facility continued to follow doctor's orders and provided extra care and supervision. No deficiencies were cited.
Report Facts
Complaint Control Number: 24-AS-20221011105453
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Salazar | Licensing Program Analyst | Conducted the complaint investigation |
| Shawniee Jackson | Executive Director | Facility representative met during investigation |
Inspection Report
Census: 76
Capacity: 162
Deficiencies: 0
Date: Feb 23, 2023
Visit Reason
The visit was an unannounced Case Management visit to relay information about an Immediate Exclusion order for a staff member (S1).
Findings
No deficiencies were cited during this Case Management visit. The Executive Director confirmed that the excluded staff member was never associated with the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawnee Jackson | Executive Director | Met with Licensing Program Analyst during the Case Management visit and provided information about staff exclusion. |
Inspection Report
Annual Inspection
Census: 91
Capacity: 162
Deficiencies: 0
Date: Aug 26, 2022
Visit Reason
The visit was an unannounced required annual infection control inspection conducted to assess compliance with infection control procedures.
Findings
The facility was found to be in compliance with required infection control practices, including symptom screenings, PPE use, visitation policies, and hygiene measures. No deficiencies were cited during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawniee Jackson | Executive Director | Met with Licensing Program Analyst during inspection and identified as Infection Control lead for the facility. |
Inspection Report
Census: 91
Capacity: 162
Deficiencies: 3
Date: Aug 26, 2022
Visit Reason
An unannounced case management visit was conducted based on reporting requirements and incident follow-up.
Findings
The inspection found that sharp items were accessible to residents with dementia, staff lacked required dementia care training, and an incident report was submitted late, posing immediate and potential risks to residents.
Deficiencies (3)
Sharp items such as screwdriver, hammer, meat thermometer, pizza slicer, and wood skewer sticks were accessible to residents with dementia.
Staff did not have the required eight hours of in-service training on dementia care; 5 out of 5 staff lacked this training.
An incident report dated 07/26/22 was submitted late, violating reporting requirements.
Report Facts
Residents in Assisted Living area: 75
Residents in Memory Care unit: 11
Staff lacking required dementia training: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawniee Jackson | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Lisa Salazar | Licensing Program Analyst | Conducted the inspection and authored the report |
| Melinda Hoffmann | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 162
Deficiencies: 0
Date: Feb 18, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 10/05/2021 regarding medication mismanagement, inadequate care and supervision, insufficient diapering supplies, and rodent infestation.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations were false and/or without reasonable basis.
Findings
The investigation found the complaint to be unfounded with no deficiencies cited. The Licensing Program Analyst reviewed records and conducted interviews, concluding the allegations were false or without reasonable basis.
Report Facts
Capacity: 162
Census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Salazar | Licensing Program Analyst | Conducted the complaint investigation |
| Shawniee Jackson | Executive Director | Facility representative met during investigation |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 162
Deficiencies: 0
Date: Feb 18, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that a resident fell multiple times while in care as a result of neglect, sustaining a fracture and hematoma.
Complaint Details
The complaint was unsubstantiated after investigation. The resident fell multiple times resulting in injury, but evidence did not prove neglect occurred.
Findings
The investigation found that the resident's health declined and they were admitted to Hospice and moved to the Memory Care unit. The resident was non-compliant with using their walker. The facility responded immediately by calling 911 and seeking medical treatment. The allegation was unsubstantiated due to lack of preponderance of evidence. No deficiencies were cited during the visit.
Report Facts
Complaint Control Number: 24-AS-20210924163703
Capacity: 162
Census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Salazar | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Shawniee Jackson | Executive Director | Facility representative met during investigation |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 162
Deficiencies: 2
Date: Dec 17, 2021
Visit Reason
The visit was an unannounced 10-day site inspection conducted due to complaint allegations at the facility.
Complaint Details
The inspection was conducted in response to complaint allegations. The report does not state substantiation status.
Findings
The inspection found furniture blocking two of four emergency exit doors in the memory care unit and incomplete construction in the lobby and resident hallway, posing potential risks to health and safety.
Deficiencies (2)
Furniture intentionally blocking exit doors in the Generations (memory care unit), violating fire safety regulations.
Facility lobby and resident hallway in disrepair and under incomplete construction, violating maintenance and operation requirements.
Report Facts
Deficiency due date: Dec 20, 2021
Deficiency due date: Dec 31, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawniee Jackson | Executive Director | Facility administrator who authorized report signing via telephone |
| Debra Sanchez | Lead Concierge | Met with Licensing Program Analysts during inspection and exit interview |
| Lisa Salazar | Licensing Program Analyst | Conducted inspection and signed report |
| Melinda Hoffmann | Licensing Program Manager | Supervised inspection and named in report |
Inspection Report
Census: 84
Capacity: 162
Deficiencies: 2
Date: Oct 13, 2021
Visit Reason
The inspection was a 10-day required site inspection conducted to assess compliance with food service regulations, specifically focusing on case management deficiencies.
Findings
The Licensing Program Analyst observed multiple food safety violations including uncovered and exposed food items such as pancake mix, flour, green Jell-O, rice pudding, and ice cream, which did not meet California Code of Regulations requirements.
Deficiencies (2)
Plastic bins in the pantry containing pancake mix and flour were uncovered and exposed to the environment.
Green Jell-O and rice pudding stored in the walk-in fridge were uncovered and exposed to the environment; ice cream in the freezer was uncovered.
Report Facts
Capacity: 162
Census: 84
Deficiencies cited: 2
Plan of Correction Due Date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawniee Jackson | Executive Director | Met during inspection and named in report |
| Lisa Salazar | Licensing Program Analyst | Conducted inspection and signed report |
| Melinda Hoffmann | Licensing Program Manager | Named as supervisor and licensing program manager |
Inspection Report
Capacity: 162
Deficiencies: 1
Date: Sep 29, 2021
Visit Reason
The visit was a case management visit to return files and address reporting issues related to an incident involving a resident that was not reported to the licensing agency.
Findings
The Licensing Program Analyst observed construction work in the facility and noted a failure to report an incident involving a resident to the Community Care Licensing agency. A deficiency was cited for failure to meet reporting requirements under Title 22, Division 6, Chapter 8, Section 87211(a)(1)(D). A plan of correction was discussed with the Executive Director.
Deficiencies (1)
Failure to submit a written report to the licensing agency within seven days of an incident threatening the welfare, safety, or health of a resident, including psychological abuse or unexplained absence.
Report Facts
Capacity: 162
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawniee Jackson | Executive Director | Met with Licensing Program Analyst during case management visit and discussed plan of correction |
| Mary Garza | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Melinda Hoffmann | Licensing Program Manager | Named as Licensing Program Manager overseeing the case |
Inspection Report
Routine
Census: 98
Capacity: 162
Deficiencies: 0
Date: Jul 28, 2021
Visit Reason
The inspection was an unannounced Infection Control Inspection conducted as a required one-year visit to assess compliance with infection control practices, including COVID-19 related procedures.
Findings
The facility was found to be in compliance with required infection control practices, including symptom screenings, PPE use, visitation protocols, and hygiene measures. No deficiencies were cited during the inspection.
Report Facts
Capacity: 162
Census: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawniee Jackson | Executive Director | Met with Licensing Program Analyst during infection control inspection |
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