Cedar Creek Senior Living

Type of visit: Case Management - Other

On 08/07/2026, Licensing Program Analyst (LPA) V Gorban made an unannounced visit for the purpose of the visit to follow up with plan of correction to complaint investigation, control number (24-AS-20260316095816). LPA met with Maria to follow up with case management for missing resident records. Based on records review and interviews, the licensee failed to ensure separate, complete and current records is maintained for each resident and is readily available for facility staff and Licensing. Citation was issued per Title 22. Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to for facility records.the state’s words, verbatim · CDSS document, Aug 7, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Aug 10, 2026

87506 Resident Records. (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not observed as evidenced by: The Licensee failed to ensure that a separate, complete and current record is maintained for each resident and is readily available. Resident (LIC621) personal property and valuables records were not available and/or provided when requested which poses potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 7, 2026

Plan of correction: The facility Licensee will review and ensure each resident record is complete and have required separate, complete, and current record. POC to be provided to LPA by email by POC due date.

Type of visit: Case Management - Annual Continuation

On 08/05/2026, Licensing Program Analysts (LPAs) M. Medina and K. Brown arrived to the facility unannounced to conduct an annual required inspection. LPAs stated the purpose of the visit and were allowed entry into the facility. LPAs met with Health & Wellness Director, Lupe Fierros who conducted the tour of the facility with LPA Brown. LPA Medina reviewed a sample of staff and resident files and observed the files to have the required documentation and staff training's. LPA reviewed Emergency Disaster plan and observed the binder to have the required updated information. LPA Brown will document the physical plant tour and inspection tool results on a separate report. No deficiencies cited.the state’s words, verbatim · CDSS document, Aug 5, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) K. Brown and M. Medina arrived unannounced to conduct the Annual Inspection. LPAs met with and explained the reason for the visit with Health Services Director (HSD) Lupe Fierros During this visit, LPA Brown toured the facility with HSD including Independent Living, Assisted Living and Memory Care. Resident apartments and common areas were clean, in good repair containing required furnishings and lighting. LPA observed required items in bathrooms which were clean with hot water measuring between 113-115 degrees. LPA observed hygiene items, paper products, towels, extra bedding, and linens which were available for use in all areas. The kitchen was clean, containing necessary cooking items and appliances. LPA observed required food supply, including emergency food. There is a medication room located in Memory Care and in Assisted Living. Medications are centrally stored and distributed by Med Techs. Doors and passageways are unobstructed throughout the facility including outdoors. LPA walked outside to find the grounds well-kept with patios, walkways and seating areas. Delayed Egress was in working order from Memory Care. Fire extinguishers were 1/8/26 by Johnson Controls. The Fire sprinkler system inspection was conducted 6/23/26. During this visit, LPAs conducted resident and staff file reviews including a medication audit. Fire and Emergency Drills are up to date. LPAs observed the following deficiencies during today’s inspection: -Medications and Cleaning supplies were accessible in resident apartments -Employee and Resident files were incomplete and not up to date -An oven in Memory Care is accessible to residents and needs a protective mechanism to prevent access -The facility does not have a designated Administrator and has not notified CCLD of the vacancy SEE LIC809-C FOR CONTINUATION OF THIS REPORT Annual - Page 2 Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D An exit interview was conducted, a Plan of Correction was developed with HSD and a copy of this report was provided. LPA requested the following updated forms faxed to CCLD by 8/7/2026 - Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Client Roster (LIC 9020) and Proof of current Liability Coverage.the state’s words, verbatim · CDSS document, Aug 5, 2026

Allegation investigated: Staff did not prevent resident in care from leaving the facility without supervision

On 04/02/2026, Licensing Program Analyst (LPA) V Gorban visited the facility to commence complaint investigation. LPA met with the Health and Wellness Director Lupe Fierros stated the purpose of the visit and allowed entry. Administrator was notified of Licensing visit but was not able to attend it. During this visit of the complaint investigation, LPA conducted a tour of the facility, interior and exterior to ensure there is no potential or immediate health and safety risk at the facility, documents were reviewed, interview conducted, and information gathered. Allegation: Staff did not prevent resident in care from leaving the facility without supervision. Based on records reviews, resident with diagnose of dementia left facility unassisted and was located by local law enforcement and retuned to the facility therefore, the preponderance of evidence has been met, the above allegation is found to be SUBSTANTIATED. An exit interview was conducted. A copy of this report and appeal rights was provided to health and wellness director, whose signature on this form confirms receipt of this report. Substantiatedthe state’s words, verbatim · CDSS document, Apr 2, 2026 · control 24-AS-20260327132952

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Apr 3, 2026

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not observed as evidenced by: Based on records reviews, resident 1 (R1) with diagnose of dementia walked out of the facility unassisted on 3/25/26, later, the same day was located by law enforcement and returned to the facility which poses health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 2, 2026

Plan of correction: The facility implemented 30 min staff watch on R1. The facility staff received AWOL / Elopement drill. The facility updated resident care plan. The formal report to be [provide to LPA by email by POC due date.

Type of visit: Case Management - Annual Continuation

On 08/14/2025, Licensing Program Analyst (LPA) Daiquiri Boyd made an unannounced visit for the purpose of completing the Annual Inspection. LPA met with Executive Director(ED) Robert Huntley to continue this inspection. Dining Room, Kitchen, and Memory Care kitchen needed cleaning of walls, cabinets, drawers, and refrigerator. Evidence of bugs observed in Memory Care kitchen cabinet Two items opened and not stored/closed properly in pantry and refrigerator, food items not labeled Sink plumbing was observed to be leaking or in need of repair. Cleaning chemicals and Sterno-burner fuel were observed in an unlocked cabinet in main Dining Room. LPA reviewed Infection Control Plan and found that it was reviewed on 7/30/25. An updated Emergency and Disaster Plan is needed as the form that was used is outdated. LPA reviewed Fire System documentation and found it was tested and cleared on 3/24/25. Carbon Monoxide detectors are dual with smoke detectors in the cottages and there are separate units outside of the kitchen and the boiler rooms. These are tested by maintenance monthly. All were in working order. Facility to provide updated LIC610E-Emergency and Disaster Plan, current Liability Insurance, and LIC500 to Licensing by 8/25/2025 Citations were issued per Title 22. Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Executive Director Robert Huntley.the state’s words, verbatim · CDSS document, Aug 14, 2025

Type of visit: Required - 1 Year

On 8/11/25, Licensing Program Analyst (LPA) Daiquiri Boyd conducted a required unannounced Annual Inspection visit. LPA introduced herself and stated purpose of visit. Executive Director (ED), Robert Huntley came from his office and assisted in the inspection. Facility has a capacity of 162 with a current census of 97. Many residents have their own individual rooms, while other residents live with their spouse. Some of the living units have a kitchen or a small kitchenette and private bathrooms. LPA observed the facility to be clean, clutter free, and odor free. LPA observed 4 rooms in the Assisted Living unit and found water temperatures to be from 117 - 117.8 degrees F. Exterior of building was toured. LPA toured 2 individual living cottages in Independent Living and found them to be clean and comfortable and water temperatures to be at 118.6 degrees F. Homes were clean and well maintained. LPA toured 1 unit in the Memory Care wing and found it to be clean and comfortable and water temperature at 113 degrees F. Kitchen was toured in Memory Care. Main Kitchen was toured. LPA reviewed a sample of staff files which are complete and up to date. LPA observed staff training to be current. LPA reviewed a sample of resident files which are complete and up to date. No citations were written on this date. Annual inspection was not completed at this time and will be completed at a later date.the state’s words, verbatim · CDSS document, Aug 11, 2025

Type of visit: Case Management - Deficiencies

On 04/17/2025, Licensing Program Analyst (LPA) Rachel Bruce conducted an unannounced Case Management visit. LPA introduced self and met with Kelly Reynolds, Administrator (AD) and explained the reason for the visit. LPA arrived at the facility to conduct a case management visit relating to an Incident Report sent to CCL and received via fax on 4/11/2025. The incident report was regarding R1 (see confidential names list) who was photographed without permission while using the restroom. The photograph/video was taken by staff member (S1) who then forwarded the photo to a former staff member (S2) who then contacted the facility to report what she had received. AD relayed to LPA that R1 was not aware of the photo being taken and had not provided permission. Madera Police Department conducted an investigation and because there were no genitals in the picture they did not press charges. S1 was first placed on administrative leave and then officially terminated by the facility on 4/14/2025. No current staff in the facility has admitted to receiving a copy of the photo/video. LPA conducted interview with AD received copies of the photo screen shot, the termination notice to S1, along with contact and report information from the Madera Police Department. Citation will be issued at todays visit. See attached 809D.the state’s words, verbatim · CDSS document, Apr 17, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 874681(1)(3) · Plan of correction due date: Apr 25, 2025

Personal Rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. (3) To be free from punishment, humiliation, intimidation, abuse, ... This requirement was not met as evidenced by 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.the state’s words, verbatim · CDSS document, Apr 17, 2025

Plan of correction: The AD stated that mandatory training is already scheduled for 4/24/2024. All staff will be required to attend. AD has contacted hte local ombudsman who has agreed to conduct the training which will cover mandated reporting and personal rights. Documentation of training conducted will be provided by due date of 4/25/2025.

Type of visit: Case Management - Other

On 04/8/2025, Licensing Program Analysts (LPAs) Rachel Bruce and Jimmy Duarte conducted an unannounced Case Management visit. LPAs introduced self and met with Kelly Reynolds, Administrator (AD) and explained the reason for the visit. LPAs arrived at the facility to conduct case management visit to relay information about Immediate Exclusion order for Staff (S1). AD was advised an exclusion has been ordered and issued by the Department and provided an exclusion order document for the S1. LPAs verified with AD that S1 has never worked in the facility or been associated. LPAs verified that S1 is not associated or ever has been to the facility staff roster and guardian. No deficiencies sited during this Case Management visit. Exit interview was conducted, report signed on-site, and a copy of this report will be provided to AD for facility records. See confidential names list attached.the state’s words, verbatim · CDSS document, Apr 8, 2025

Type of visit: Case Management - Incident

On 3/13/2025, Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to conduct a case management visit. LPA met with Administrator (AD) Kelly Reynolds and explained the reason for the visit. CCL received an incident report in January, 2025 regarding Resident (R1) whose family called 911 to have him go to the hospital for a foot ulcer. LPA inquired if R1 had entered the facility with the issue or if had developed the ulcer while under their care. LPA was provided with a copy of R1's pre assessment which reflected that there was an existing foot wound at the time he came under their care. R1's family called 911 to get his foot addressed as they felt that they wanted him to have the doctor look at it. R1 had alot of medical issues at the time and the foot ulcer was just one of R1's medical concerns. R1 entered the facility on January 10 and went to the hospital on January 19, 2025 for his foot. R1 never did return to the facility and ultimately passed away on February 9, 2025 due to medical conditions not necessarily related to the foot ulcer. LPA and AD discussed pre-assessments and incident reporting and the need to include as much information as possible. No citations issues at today's visit. See LIC811 for confidential names list.the state’s words, verbatim · CDSS document, Mar 13, 2025

Type of visit: Case Management - Other

On 11/7/24 Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to conduct a case management visit. LPA met with Administrator Kelly Reynolds and explained the reason for the visit. LPA reviewed R1's file which contains R1's admission agreement showing when R1 signed the admission agreement they were their own responsible party. LPA reviewed copies of outstanding notices previously given to R1. Statements show a reoccurring balance on each statement, and AD stated there have been multiple verbal conversation with R1 and Ombudsman regarding the situation. LPA inquired on a death report received for R2 on 10/6/2024. R2 passed on 9/26/24 and a written report should be submitted within 7 days. The 7th day from 9/26/24 would have been 10/3/2024. Deficiency was cited under Title 22. Exit interview was conducted and a copy of this report LIC809, LIC809D, LIC421FC, and appeal rights were provided to Kelly Reynolds.the state’s words, verbatim · CDSS document, Nov 7, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Nov 22, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Based on observation, interview, & record review the licensee did not comply with the regulations listed above. This poses a potential health, safety, or personal rights risk to residents in care. The Administrator did not comply with the regulation listed above due to R2's death report not being submitted to the Dept within the required 7 days.the state’s words, verbatim · CDSS document, Nov 7, 2024

Plan of correction: Administrator will meet with staff who submits reports to the Dept.

Type of visit: Case Management - Incident

On 9/9/2024 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct a case management visit to follow-up on incident reports received. LPA met with Business Office Director (BOD) Deborah Sanchez. Maintenance Director (MD) Jeff Hicks provided a copy of the invoice from the boiler being serviced. The boiler went out on 8/10/24 and was fixed on 8/22/24. LPA asked what plan was put into place, BOD stated there were empty rooms that were offered to the residents. BOD stated certain areas upstairs were effected by the boiler going out. LPA spoke with R1 who stated they were without water for a bit but it is fixed and everything is alright. LPA asked MD & BOD why it took so long to get the boiler fixed, MD stated the part was obsolete and had to be ordered. MD also stated the part was shipped from the East Coast and during that time there were weather issues which could have caused the delay. MD stated they are ordering additional parts in case the part goes out in other broilers. LPA spoke with Health & Wellness Director (HWD) Lupe Fierros regarding incident reports the Dept received for R2, R3, and R4. R2 passed away on 8/30/24 at the hospital. R2 was diagnosed with Type 2 Diabetes but was managed by diet. LPA did not find any deficiency with R2's care. R3 was sent to the hospital on 8/28/24. LPA interviewed R3 who stated they fell in the kitchen. LPA asked how long it took for R3 to go to the hospital but R3 was not able to give an answer. Cause of fall is unknown. R4 is currently at the hospital. LPA spoke with HWD who stated R4 has a blood sugar monitor on their arm and it is changed every 14 days by R4's sister. R4's last Physician Report was completed on 5/24/24 which states R4 cannot manage medications, cannot administer their own medication, cannot administer own injections, and cannot perform own glucose testing. No deficiencies were found during this visit and no citations were issued. Exit interview was conducted and a copy of this report was provided to Health & Wellness Director (HWD) Lupe Fierros.the state’s words, verbatim · CDSS document, Sep 9, 2024

Type of visit: Case Management - Annual Continuation

On 7/22/24 Licensing Program Analysts (LPAs) B. Miranda & M. Vega arrived at the facility unannounced to continue the annual inspection. Front desk was informed of the reason for the visit and Executive Director Kelly Reynolds arrived shortly after. LPAs toured the inside and outside of the facility. When LPAs arrived, breakfast was being served. LPAs observed residents eating and interacting with one another. LPAs observed the following deficiencies: 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 were left unlocked and accessible to residents in the coffee/tea area to the right of the entrance Kitchen has meat defrosting with blood and not properly stored Freezer has multiple items opened and not stored/closed properly, food items not labeled 1 Strawberry pack was rotting Puddle of water next to the ice machine, mildew inside of 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 During the tour LPAs observed the facility to be odor free. Citations were issued per Title 22 Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Executive Director Kelly Reynolds.the state’s words, verbatim · CDSS document, Jul 22, 2024

Allegation investigated: Staff did not report incidents involving resident as required.

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 and a copy of this report LIC9099, LIC9099D, and appeal rights were provided to Executive Director Kelly Reynolds. Substantiatedthe state’s words, verbatim · CDSS document, Jul 15, 2024 · control 24-AS-20240304133818

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jul 29, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Based on observation, interview, & record review the licensee did not comply with the regulations listed above. Responsible party was notified verbally and not in writing.the state’s words, verbatim · CDSS document, Jul 15, 2024

Plan of correction: Executive Director Kelly Reynolds stated a document has been created to notify responsible party in writing. Copy will be provide to LPA.

Allegation investigated: Staff did not prevent resident from being assaulted by another resident. Staff did not prevent resident from being exploited.

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. Unsubstantiated Although the allegations 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 allegations are unsubstantiated. Exit interview was conducted and a copy of this report LIC9099 & LIC9099C were provided to Executive Director Kelly Reynolds.the state’s words, verbatim · CDSS document, Jul 15, 2024 · control 24-AS-20240304133818

Type of visit: Required - 1 Year

On 7/15/24, Licensing Program Analysts (LPAs) B. Miranda & M. Vega conducted a required unannounced Annual Inspection visit. LPAs introduced themselves and stated purpose of visit. Executive Director Kelly Reynolds was contacted and met with LPAs. Facility has a capacity of 162 with a current census of 87. Residents have their own individual rooms with their own bathrooms. LPAs observed the facility to be clean, clutter free, and odor free. LPAs reviewed infection control plan and disaster plans which are current and complete. LPAs reviewed a sample of staff files which are complete and up to date. LPAs observed staff training to be current. LPA reviewed a sample of resident files which are complete and up to date. Annual inspection was not completed at this time and will be completed at a later date. No citations were issued during today's visit. Exit interview was conducted and a copy of the report LIC809 was provided to Executive Director Kelly Reynoldsthe state’s words, verbatim · CDSS document, Jul 15, 2024

Allegation investigated: Facility is in disrepair Facility does not provide a safe environment for the residents in care

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. Unsubstantiated 2. The Department investigated the allegation: Facility does not provide a safe environment for the residents in care. LPA conducted interviews with 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. After conducting interviews, observing the facility, and record reviews the LPA found there to not be enough evidence for the allegations. 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 LIC9099 was provided to Executive Director Kelly Reynolds.the state’s words, verbatim · CDSS document, Feb 7, 2024 · control 24-AS-20231009162701

Allegation investigated: Staff do not provide adequate supervision resulting in residents wandering away from facility Facility was left without electricity Staff do not provide adequate food service Resident Council is ran by facility staff Staff do not provide activities to residents in care.

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 were brought out quickly to help assist with the situation. Unsubstantiated 3. The Department investigated the allegation: Staff do not provide adequate food service. LPA reviewed current facility menu, observed food supply in kitchen, 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. 4. The Department investigated the allegation: Resident Council is ran by facility staff. LPA conducted interviews with staff and residents. Interviewees stated which residents were in charge of the Resident Council, LPA attempted multiple times to interview members of the Resident Council which were unsuccessful. 5. The Department investigated the allegation: Staff do not provide activities to residents in care. LPA reviewed the activities calendar which had different activities listed throughout the month. LPA interviewed staff and residents. Interviewees verified there was one time during the month activities were cancelled due to a situation that took place that day with the activities director. After conducting interviews, observing the facility, and record reviews the LPA found there is not enough evidence for the allegations. 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 allegations are unsubstantiated. Exit interview was conducted and a copy of this report LIC9099 was provided to Executive Director Kelly Reynolds.the state’s words, verbatim · CDSS document, Feb 7, 2024 · control 24-AS-20231009155452

Allegation investigated: Ventilation returns in the hallways are filthy Kitchen nutrition is poor Activities canceled & not enough for residents to do Tables not being sanitized Kitchen staff not wearing hair nets or masks during food prep Facility had no certified drivers in December and allowed staff to drive commercial vehicles

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. Unsubstantiated 3. The Department investigated the allegation: Activities canceled & not enough for residents to do. LPA reviewed the activities calendar which had different activities listed throughout the month. LPA interviewed staff and residents. Interviewees verified there was one time during the month activities were cancelled due to a situation that took place that day with the activities director. 4. The Department investigated the allegation: Tables not being sanitized. On 1/25/24 LPA toured the dining area of the facility and the areas with tables. LPA observed the dining tables to be clean and set to serve the next meal. LPA conducted interviews with staff and residents. Staff stated there is procedure in place that all tables are cleaned and sanitized after every meal, there is assigned staff who clean and sanitize the tables and areas throughout the facility. 5. The Department investigated the allegation: Kitchen staff not wearing hair nets or masks during food prep. On 1/25/24 when LPA toured the kitchen of the facility which only had one staff member at the time. LPA conducted interviews with staff who stated gloves are worn while food is being prepared and served. Per Title 22 there is no specifics requiring hairnets or masks. 6. The Department investigated the allegation: Facility had no certified drivers in December and allowed staff to drive commercial vehicles. LPA conducted interviews with staff and residents. Interviewees stated the vans at the facility are bing used at this time since there is no certified driver to drive the facilities commercial vehicles. After conducting interviews, observing the facility, and record reviews the LPA found there not to be enough evidence for the allegations. 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 allegations are unsubstantiated. Exit interview was conducted and a copy of this report LIC9099 was provided to Executive Director Kelly Reynolds.the state’s words, verbatim · CDSS document, Feb 7, 2024 · control 24-AS-20240125103121

Type of visit: Case Management - Other

On 01/25/24 at 12:55 p.m.Licensing Program Analyst (LPA) B. Miranda entered the facility unannounced to collect original reporst and provide amended reports. LPA was greeted and met with Executive Director Kelly Reynolds & Administrator Kimberly Elderidge. LPA explained the reason for the visit. LPA explained the original reports needed to be collected due to report needing to be amended. LPA collected the original reports and provided a copy of the amended LIC9099s to Executive Director Kelly Reynolds. Exit interview conducted, original reports were collected, and a copy of the amended reports provided.the state’s words, verbatim · CDSS document, Jan 25, 2024

Type of visit: Office

An informal meeting was held on 01/16/2024 via teleconference. The purpose of the informal meeting was to discuss the findings of the Solvency Audit for Cedar Creek. The informal meeting process was explained during this meeting. The following were in attendance: Brenda White- Regional Office Manager (ROM) Brenda Chan- Licensing Program Manager (LPM) Brianna Miranda- Licensing Program Analyst (LPA) Kimberly Eldridge- Administrator (AD) Kelly Reynolds- Executive Director (EX) Erika Castile - VP of Operations (VPO) Ben Levesque - Executive VP of Operations (EVPO) Holly McMurray - VP of Compliance (VPC) A Solvency Audit was initiated and conducted for Cedar Creek after the Fresno Regional Office received a complaint on 6/26/23 alleging the facility was in financial distress. When the audit initially started Cedar Creek was being managed by Integral SR LVG MNGNT LLC. Cogir SL Cedar Creek LLC took over as the management company for Cedar Creek and is the current management company. During the meeting the following will be discussed: • CCR, Title 22, Division 6, Section 87205 Accountability. LPM explained the reason for the meeting was to review the findings of the audit. EVPO explained Cogir has placed a new Administrator (AD). Currently EX oversees the facility until the transitions has been completed and requirements have been met for EX to be Administrator. The current census is 74. EVPO explained the owners are the same only the management companies have changed. EVPO stated Cogir is able to meet the capacity needs, mitigate any issues, and able to meet financial requirements. LPM asked how the facility explain how utilities, control of properly, and resident’s needs will be met and maintained. EVPO explained Cogir has not had any financial issues in the past. PG&E has been placed on automatic payment, Cogir will provide current bills. EVPO stated for operations there is enough funds to cover expenses, payable will be managed. There are short term and long-term goals implemented. EVPO states there is sufficient number of staff to care for resident’s and their needs. LPM informed attendees of TSP (Technical Support Program), and informed them to utilize the website. Attendees were also informed of Noncompliance Conference (NCC) and the Dept. may seek legal advice. LPM explained there will be an increase in frequency of visits to monitor facility is complying. Cogir will provide a written plan describing full compliance and will be received by the Fresno Regional Office by 02/01/2024. The following documentation will also be included: current worker’s comp policy, verification for control of property/lease agreement, documentation verifying facility is no longer is financial distress, and a current facility sketch. Citations were issued under Title 22, Division 6, Chapter 8. Exit interview was conducted and a copy of this report LIC809, LIC809-D, and appeal rights were provided to AD- Kimberly Eldridge via email. Administrator will manually sign reports and send back.the state’s words, verbatim · CDSS document, Jan 16, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87205(a) · Plan of correction due date: Jan 17, 2024

87205 Accountability of Licensee Governing Body (a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. This requirement is not met as evidenced by: Based on the Department's review of records and information gathered the licensee failed to maintain financial position. Overall, the licensee is not in a good financial position. The licensee had insufficient and negative cash reserves at bank, during the review period from June 2022 to May 2023. Based on documentation and information provided, licensee does not have an adequate financial plan required by law and is not in a good financial position. This poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 16, 2024

Plan of correction: EVPO- Ben Levesque stated a written plan describing full compliance will be created and will be received by the Fresno Regional Office by 02/01/2024.

Type of visit: Case Management - Incident

On 11/30/23 at 10:31 a.m. Licensing Program Analyst (LPA) B. Miranda entered the facility unannounced to conduct a case management visit regarding an incident report the Department received on 11/27/23. The incident report stated on 11/17/23 the facility received a 7-day shut off notice from PG&E. LPA introduced herself and explained the reason for the visit. LPA met with Executive Director Kelly Reynolds (ED). LPA conducted a walk around tour of the facility and verified there was no immediate danger. LPA observed the 7-day notice which had the statement date of 11/17/23 with a due date of 11/29/23. Facility made payment for the full outstanding amount on 11/28/23. LPA collected the following documents from the visit: Copy of 7-day PG&E notice, and copy of online payment. LPA asked RCD to provide a statement explaining action taken to prevent the facility from receiving shut off notices, and a statement explaining how this incident reoccurred. LPA explained if the incident report is not correct to send a revised incident report. Statements are due by 12:00 p.m. on 12/1/23. At this time no citations or civil penalties were issued, citations and civil penalties may be issued at a later date. Exit interview was conducted and a copy of this report LIC809 was provided to ED Kelly Reynolds.the state’s words, verbatim · CDSS document, Nov 30, 2023

Type of visit: Case Management - Annual Continuation

On 11/16/23 Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to completed the annual inspection which was originally started on 7/27/23. Management companies have changed and Kimberly Jones is no longer at the facility since 11/1/23. LPA spoke with Kelly Metz and Kimberly Eldridge. LPA had previous conducted the tour on 7/27/23 and was at the facility today to complete the care tool part of the annual inspection. During the visit on 7/27/23 facility was not able to provide current annual training for staff members Facility was not able to provide current first aid/CPR cards for staff members. Updated cards were provided today Plan of operation is to be readily available at the facility and it was not. On 7/27/23 LPA observed various areas of the facility needing to be cleaned On 7/27/23 LPA found cleaning products & scissors not locked away and available to residents in care in the Generations area of the facility. On 7/2/23 LPA observed kitchen staff to not be wearing gloves when handling food items and food items subject to cross contamination due to being stored improperly Emergency contact information is not up to date in resident's charts. Modifications were not attached to resident's admission agreements Kitchen cleaning supply closet could not properly close Citations were issued today and have been entered into LIC809D. Exit interview was completed. A copy of this report LIC809, LIC 809D, and appeal right were provided to Kelly.the state’s words, verbatim · CDSS document, Nov 16, 2023

Allegation investigated: Staff did not make all licensing reports issued by CCL accessible to residents

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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 9, 2023 · control 24-AS-20230626140051

Allegation investigated: Facility is in financial distress. Medication was accessible to residents in care. Staff do not ensure kitchen is clean.

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. Substantiated 2. The Department investigated the allegation: Medication was accessible to residents in care. LPA interviewed staff who stated there was an incident where medication from one resident was left in another resident’s room unattended. This incident occurred in the Generations area where there are dementia residents. No documentation was maintained regarding the situation. 3. The Department investigated the allegation: Staff do not ensure kitchen is clean. The facility was previously cited for facility is dirty on 7/5/23. Please reference complaint # 24-AS-20230306123828 to view citing. The above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, and was previously cited. The kitchen was noted in this complaint. Based on LPAs observations and interviews which were conducted and record review(s), 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 Two citations were issued today for the three allegations listed above since one allegation was previously cited on 7/5/23 it was not cited again today. Exit interview was conducted and a copy of this report LIC909 , LIC9099D, and appeal rights were given to RCD Kimberly Jones. This report has been amended. A copy of the amended report LIC809 was provided to Kelly Reynolds.the state’s words, verbatim · CDSS document, Oct 9, 2023 · control 24-AS-20230626113948

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Oct 10, 2023

87213 Finances The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents; shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency. Such request shall explain the need for disclosure. The licensing agency reserves the right to reject any financial report and to request additional information or examination including interim financial statements. This requirement is not met as evidenced by: Based on observation, interview, & record review the licensee failed to maintain finances due to unpaid bills which stopped services from vendors and received potential shut-off notices from utility company. This poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 9, 2023

Plan of correction: LPA met with Business Office Director who provided verifiation of payment for outstanding bills.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Oct 10, 2023

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on observation, interview, & record review the licensee failed to keep medication inaccessible to residents in care. This poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 9, 2023

Plan of correction: Facility had staff inservice regarding medication. RCD will provide verficiation to LPA.

Allegation investigated: Facility is in disrepair Facility is unsanitary Staff failed to provide a comfortable environment for residents

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. Unsubstantiated 2. The Department investigated the allegation: Facility is unsanitary LPA toured the facility on 7/27/23 and did not find any issues with the facility being unsanitary. LPA had previously conducted staffed interviews and spoke with residents in the common area who did not report any issues regarding this allegation. 3. The Department investigated the allegation: Staff failed to provide a comfortable environment for residents. LPA previously toured the facility on 7/5/23 and did not observe any residents to be uncomfortable. LPA spoke with residents who were in the common areas and did not have complaints to report. 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.the state’s words, verbatim · CDSS document, Oct 9, 2023 · control 24-AS-20230626092401

Allegation investigated: Staff did not properly notify resident's responsible party of rate increase. Staff did not allow resident’s responsible party to participate in decision-making regarding the care and services provided to the resident.

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. Substantiated 1. The Department investigated the allegation: Staff did not allow resident’s responsible party to participate in decision making regarding the care and services provided to the resident. LPA conducted interviews and reviewed records. Facility did not follow the admission agreement which stated there would be a certain amount of time allowed before changes to resident's care took place. The facility did not follow the admission agreement with proper written notice given to reporting party. Based on LPAs observations and interviews which were conducted and record review(s), 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 & HSC 1569.655 are being cited on the attached LIC 9099D Exit interview was conducted and a copy of this report LIC909 , LIC9099D, and appeal rights were given to RCD Kimberly Jones.the state’s words, verbatim · CDSS document, Oct 9, 2023 · control 24-AS-20230807083425

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.655 · Plan of correction due date: Oct 16, 2023

§1569.655 Increase in fee rates for elderly residents; 60 days’ written notice stating amount of and reasons for increase; application of section (a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident. This subdivision shall not apply to optional services that are provided by individuals, professionals, or organizations under a separate fee-for-service arrangement with residents. This requirement is not met as evidenced by: Based on observation, interview, & record review the licensee failed to give responsible party the proper 60-days notice in writing of fee increase. This poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 9, 2023

Plan of correction: ED will continue to notify promptly to notify of any increases. Explaination will be sent to LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Oct 16, 2023

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by: Based on observation, interview, & record review the licensee failed to follow the notice agreement listed in the admission agreement when making changes to resident in care. This poses a potential health, safety, or personal rights risk to residents in carethe state’s words, verbatim · CDSS document, Oct 9, 2023

Plan of correction: ED will clarify and confirm with legal POA to note primary contact. Will document elder mark of changes in sysytem. Email explaining