Cedar Creek Senior Living

On 7/15/24 Licensing Program Analysts (LPAs) B. Miranda & M. Vega arrived at the facility unannounced to deliver the finding for the allegation(s) listed above. LPA introduced herself and explained the reason for the visit. Executive Director Kelly Reynolds was contacted and met with LPAs. 1. The Department investigated the allegation: Staff did not report incidents involving resident as required. LPA conducted interviews and reviewed records. LPA was informed verbal contact was made with responsible party of R1. A timely incident report was sent to the Dept. Both responsible party and the Dept must be notified of the incident in writing within 7 days. Based on LPAs observations, interviews, & record reviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, & Chapter 8, are being cited on the attached LIC 9099D. Exit interview was conducted andRead the full finding— CDSS inspection report, July 15, 2024 · control 24-AS-20240304133818

On 7/15/24 Licensing Program Analysts (LPAs) B. Miranda & M. Vega arrived at the facility unannounced to deliver the finding for the allegation(s) listed above. LPA introduced herself and explained the reason for the visit. Executive Director- Kelly Reynolds was contacted and met with LPAs. 1. The Department investigated the allegation: Staff did not prevent resident from being assaulted by another resident. LPA conducted interviews and reviewed records. R1 is in the memory side of the facility, there was a disagreement between R1 and another resident. This is an isolated event. 2. The Department investigated the allegation: Staff did not prevent resident from being exploited. LPA conducted interviews and reviewed records. LPA reviewed R1's chart and did not find updated POA for medical. At this time all paperwork remains the same. UnsubstantiatedRead the full finding— CDSS inspection report, July 15, 2024 · control 24-AS-20240304133818

On 2/7/24 Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to deliver the finding for the allegations listed above. LPA introduced herself and explained the reason for the visit. LPA met with Executive Director (ED) Kelly Reynolds and Administrator (AD) Kimberly Elderidge. 1. The Department investigated the allegation: Facility is in disrepair. On 10/13/23 LPA toured the facility and did not observe any issues within the facility regarding the facility being in despair. LPA conducted various interviews with PG&E works, facility staff and residents. There was an accident which caused the power to go out. PG&E brought generators to the facility due to the severity of the car accident and the damage it caused to the electrical lines for the facility. UnsubstantiatedRead the full finding— CDSS inspection report, February 7, 2024 · control 24-AS-20231009162701

On 2/7/24 Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to deliver the findings for the allegations listed above. LPA introduced herself and explained the reason for the visit. LPA met with Executive Director (ED) Kelly Reynolds and Administrator (AD) Kimberly Elderidge. 1. The Department investigated the allegation: Staff do not provide adequate supervision resulting in residents wandering away from facility. LPA interviewed staff and residents. On interviewee stated there was a resident who was out of memory care and was accompanied by staff. There no other issues reported. 2. The Department investigated the allegation: Facility was left without electricity. LPA conducted interviews with PG&E workers, staff and residents. Interviewees stated they understood there was a situation beyond the control of the facility, and the facility did there best to meet the residents needs. Interviewees did not state they had any concerns. PG&E stated generators wereRead the full finding— CDSS inspection report, February 7, 2024 · control 24-AS-20231009155452

On 2/7/24 Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to deliver the finding for the allegations listed above. LPA introduced herself and explained the reason for the visit. LPA met with Executive Director (ED) Kelly Reynolds and Administrator (AD) Kimberly Elderidge. 1. The Department investigated the allegation: Ventilation returns in the hallways are filthy. LPA toured the facility and did not observe ventilation returns to be dirty. LPA conducted interviews from staff and residents. Interviewees stated they have not observed the ventilation returns to be dirty. 2. The Department investigated the allegation: Kitchen nutrition is poor. LPA reviewed current facility menu, observed kitchen with food supply, and conducted interviews. LPA observed the facility to have proper food supply with food from all the different food categories. LPA observed the menu to have a proper variety of food available to residents. UnsubstantiatedRead the full finding— CDSS inspection report, February 7, 2024 · control 24-AS-20240125103121

On 10/9/2023 Licensing Program Analyst B. Miranda arrived at the facility unannounced to deliver the finding for the allegations listed above. LPA introduced herself and explained the reason for the visit. Resident Care Director (RCD) Kimberly Jones was contacted and met with LPA. 1. The Department investigated the allegation: Staff did not make all licensing reports issued by CCL accessible to residents. LPA interviewed staff. LPA was shown a binder with reports and documents are available when requested. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview was conducted and a copy of this report LIC909 was given to RCD Kimberly Jones. UnsubstantiatedRead the full finding— CDSS inspection report, October 9, 2023 · control 24-AS-20230626140051

On 10/9/2023 Licensing Program Analyst B. Miranda arrived to the facility unannounced to deliver the finding for the allegations listed above. LPA introduced herself and explained the reason for the visit. Resident Care Director (RCD) Kimberly Jones was contacted and met with LPA. 1. The Department investigated the allegation: Facility is in financial distress. On 7/5/23 LPA interviewed various staff members and documentation was reviewed showing due to non-payments vendors services were stopped and or notices were issued informing utilizes were going to be turned off. The Department was not informed of the financial distress of the facility. SubstantiatedRead the full finding— CDSS inspection report, October 9, 2023 · control 24-AS-20230626113948

On 10/9/2023 Licensing Program Analyst B. Miranda arrived at the facility unannounced to deliver the finding for the allegations listed above. LPA introduced herself and explained the reason for the visit. Resident Care Director (RCD) Kimberly Jones was contacted and met with LPA. 1. The Department investigated the allegation: Facility is in disrepair. LPA toured the facility and did not find the facility to be in disrepair at the time. There was water damage that was being repaired in the Redwood Dining area. On 7/5/23 this allegation was previously Unsubstantiated on complaint # 24-AS-20230306123828 regarding the facility is in disrepair. There were multiple complaints overlapping with one another. Multiple complaints were investigated at the same time. UnsubstantiatedRead the full finding— CDSS inspection report, October 9, 2023 · control 24-AS-20230626092401

On 10/9/2023 Licensing Program Analyst B. Miranda arrived at the facility unannounced to deliver the finding for the allegations listed above. LPA introduced herself and explained the reason for the visit. Resident Care Director (RCD) Kimberly Jones was contacted and met with LPA. 1. The Department investigated the allegation: Staff did not properly notify resident's responsible party of rate increase. LPA conducted interviews and reviewed records. Admission agreement stated there would be a certain amount of time allowed before increases took place. The facility did not follow the allowed time with proper written notice according to admission agreement. SubstantiatedRead the full finding— CDSS inspection report, October 9, 2023 · control 24-AS-20230807083425

On 8/24/23 at 1:08 p.m. Licensing Program Analyst B. Miranda arrived to the facility unannounced to deliver the findings of the allegations listed above. LPA introduced herself to receptionist and requested to speak with the Administrator Joan Johnson. Receptionist stated Administrator was not available and all other managers were not available. Marketing Director contacted Resident Care Director (RCD) Kimberly Jones who arrived shortly after. LPA met with RCD and explained the reason for the visit. 1. The Department investigated the allegation: Staff does not ensure resident's pressure injury is cleaned. LPA conducted interviews and reviewed records. Facility was not able to provide Healthcare Plan which includes services that are provided by Home Health and which services are provided by the facility including the duration of the services. Communication log indicates there was discrepancies in Home Health Providers and resident was not getting proper care for pressure injuries. ResidRead the full finding— CDSS inspection report, August 24, 2023 · control 24-AS-20230501112552

Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced. LPA met with Rsident Care Director Kimberly Jones and explained the reason for the visit. During this visit LPA delivered investigation findings regarding the above allegations. The Department has investigated the complaint alleging: Staff does not ensure resident's showering needs are being met, Staff does not provide adequate food service to resident, Staff leaves resident soiled for an extended period of time. Based on the interviews conducted and/or records review the above allegations is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview was conducted an a copy of this report was provided to Kimberly Jones. UnsubstantiatedRead the full finding— CDSS inspection report, August 24, 2023 · control 24-AS-20230501112552

On 7/5/2023 at 1:50 p.m. Licensing Program Analyst B. Miranda arrived to the facility unannounced to deliver the finding for the allegations listed above. LPA introduced herself and explained the reason for the visit with Senior Director of Sales & Marketing Gaby Alvarado. 1. The Department investigated the allegation: Staff are not following Covid-19 masking protocols. LPA toured the facility and found some employees to either not be wearing a mask or wearing the mask incorrectly. At this time is was still mandatory for all employees to wear masks while working in the facility. 2. The Department investigated the allegation: Staff do not follow procedures which protect the safety of food during preparation and service. LPA toured the facility on various occasions and found kitchen staff to not be wearing gloves while preparing food and to be without hairnets. LPA requested multiple time for training of kitchen staff and kitchen staff contact information which was never provided. SubstaRead the full finding— CDSS inspection report, July 5, 2023 · control 24-AS-20230306123828

On 7/5/2023 at 1:50 p.m. Licensing Program Analyst B. Miranda arrived to the facility unannounced to deliver the finding for the allegations listed above. LPA introduced herself and explained the reason for the visit. Senior Director of Sales & Marketing Gaby Alvarado 1. The Department investigated the allegation: Facility is in disrepair. LPA conducted 4 staff interviews and toured the facility. LPA observed certain areas of the facility needing to be cleaned. Repairs were being completed in Redwood Room. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview was conducted and a copy of this report was given to Senior Director of Sales & Marketing Gaby Alvarado UnsubstantiatedRead the full finding— CDSS inspection report, July 5, 2023 · control 24-AS-20230306123828

On 7/5/2023 at 1:50 p.m. Licensing Program Analyst B. Miranda arrived to the facility unannounced to deliver the finding for the allegations listed above. LPA introduced herself and explained the reason for the visit and met with Senior Director of Sales & Marketing Gaby Alvarado. 1. The Department investigated the allegation: Personnel records are not adequately maintained by staff. LPA interviewed staff members and observed a sample of personnel records. Relias is the system used for training. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview was completed and a copy of this report was provided to Gaby Alvarado. UnsubstantiatedRead the full finding— CDSS inspection report, July 5, 2023 · control 24-AS-20230329140137

On 7/5/2023 at 1:50 p.m. Licensing Program Analyst B. Miranda arrived to the facility unannounced to deliver the finding for the allegations listed above. LPA introduced herself and explained the reason for the visit and met with Senior Director of Sales & Marketing Gaby Alvarado 1. The Department investigated the allegation: Staff did not safeguard resident's records. During a tour of the facility LPA noticed the top half of the Medication room was not locked and was able to be unlocked from the bottom and client's records were accessible. Administrator (Shawniee Jackson) asked staff why the medication door was left open, and staff stated because they just came out of the Med Room. LPA observed Med-Tech walking from an area of a resident's rooms and not the med room. SubstantiatedRead the full finding— CDSS inspection report, July 5, 2023 · control 24-AS-20230329140137

On 6/14/2023 at 1:23 p.m. Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to open a complaint and conduct an investigation. LPA met with Resident Care Director Marilyn Couzens and explained the reason for the visit. LPA collected sample Centerally Stored Medication log, communication log, and Med Tech procedures. Marilyn will provide staff schedule for June and staff contact information by end of business day 6/19/23. 1. The Department investigated the allegation: Facility staff did not properly manage a resident's medication. LPA interviewed staff members and reviewed a sample of resident records. LPA observed Centerally Stored Medication log to not be completed. Bubble packs did not have date medication started and incorrect amount of medication in container. SubstantiatedRead the full finding— CDSS inspection report, June 14, 2023 · control 24-AS-20230612102501

On 03/07/23, Licensing Program Analyst (LPA), L. Salazar arrived to the facility unannounced to deliver findings on the above allegations. LPA was greeted by receptionist, stated the purpose of the visit and was allowed entry into the facility. During the investigation, LPA conducted interviews and records review. Based on the information received and although the allegations may have happened, there is not a preponderance of evidence to prove that the alleged violations occurred, therefore the allegations are Unsubstantiated. When Resident R1 was admitted to hospice care services, the facility did not receive a discontinue order for medications. Facility was continuing to follow doctor's order. Facility provided extra care and supervision and documented contact with the hospice agency regarding R1's condition. NoRead the full finding— CDSS inspection report, March 7, 2023 · control 24-AS-20221011105453

On 02/18/22, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to deliver findings on the above complaint allegation. 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. The Department has investigated the above allegation. Through interviews and records review that were conducted, it was documented that Resident R1’s health began to decline. R1 was admitted to Hospice on 09/21/21 and moved to the “Generations” Memory Care unit. It was documented that R1 had been non-compliant in using their walker for ambulation. The facility responded immediately, called 911 and sought medical treatment for R1. Although the allegation may have happened, there is not a preponderance of evident to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and copy of report was left withRead the full finding— CDSS inspection report, February 18, 2022 · control 24-AS-20210924163703

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. NoRead the full finding— CDSS inspection report, February 18, 2022 · control 24-AS-20211005112928