Cedarbrook Memory Care Community

Type of visit: Case Management - Incident

On 06/18/2026, Licensing Program Analyst (LPA) M Vega arrived at the facility unannounced visit to conduct Case Management visit. LPA was greeted by receptionist and stated the purpose of the visit. LPA met with Executive Director (ED) - Emily Venegas. This case management visit is being conducted for an Special Incident Report (SIR) dated 05/26/2026, LPA reviewed resident progress notes and discussed fall assessments with ED. LPA obtained documentation to ensure proper interventions are being implemented regarding falls. No deficiencies were cited. Special Incident Report (SIR) dated 06/05/2026, Incident reported R1 was sent to the ER and was diagnosed with an infection. Interview with ED disclosed that there was a hospital error regarding medication that facility was able to catch and correct. R1 was observed with a high fever on 06/06/2026 and was sent out per facility LVN request per charting notes. No deficiencies cited. At this time, the case management visit does not require follow up based on documentation provided by ED to LPA. No deficiencies cited during todays visit. Exit interview completed with Executive Director. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 18, 2026

Type of visit: Required - 1 Year

On 04/30/2026, Licensing Program Analyst (LPA) M Vega arrived at the facility unannounced to conduct Required Annual Inspection. LPA was greeted by receptionist and stated the purpose of the visit. LPA met with Executive Director (ED) - Emily Venegas. LPA conducted tour of facility with ED. A sample of residents’ files were reviewed to have updated emergency contact, Admission agreement, Needs and Services Plan and Pre-Appraisal Plan. A sample of staff files was reviewed. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel records. Staff are fingerprinted clear and associated to the facility. Residents were observed thought the facility, Residents also observed watching television, other residents were walking some sitting in different parts of the facility. Some residents were in dining area waiting for lunch and another resident was getting a haircut. Facility courtyard was toured and observed to be free from debris. There was outdoor shaded seating available for the residents. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 07/18/2025. Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer, walk-in refrigerator, and pantry. Refrigerator temperature was maintained at 32 degree F. and freezer was maintained at 0 degree F. Continuation on LIC 809C LPA toured a sample of resident bedrooms. Residents' rooms were observed with adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested at 114.9 degrees F. LPA observed securely fastened grab bars and non-skid mat in all shower areas. Medications were stored in a locked medication room in a medication cart. Medications records were reviewed in Electronic Filing system. First Aid Kit was stored in medication room and observed with all required items. LPA toured laundry room and observed chemicals were stored and inaccessible to residents in care. Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate and up to date information for your facility. In an effort to maintain your facility file, please submit the most current and complete forms and/or information as identified below: Residential Care Facility for the Elderly (RCFE) LIC 308 Designation of Facility Responsibility LIC 309 Administrative Organization LIC 400 Affidavit Regarding Client/Resident Cash Resources LIC 402 Surety Bond LIC 500 Personnel Report LIC 610E Emergency And Disaster Plan For Residential Care Facilities For The Elderly LIC 9020 Register of Facility Clients/Residents Copy of current Liability Insurance Copy of current Administrator Certificate Alternate contact information including name, telephone number, & email address. Continuation on LIC 809C Please submit the above forms/information to Fresno CCL by: 05/14/2026 As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed. No deficiencies issued during this inspection. An exit interview was conducted with the ED A copy of this report was given to ED whose signature on this form confirms receipt of these reports.the state’s words, verbatim · CDSS document, Apr 30, 2026

Type of visit: Case Management - Incident

On 12/23/25 Licensing Program Analyst (LPA), M Vega to conduct an unannounced case management visit. LPA met with Business Office Manager - Narissa Rodriguez and conducted facility tour with Business Office Manager. This case management visit is being conducted for a Special Incident Report (SIR) dated 10/26/2025, need clarification regarding Resident 1(R1) and Resident 2 (R2) interaction on 10/26/2025, LPA will request the following: (R1 and R2: 602A and 625 needs and services, both residents). At this time this case management does not need further review. Business Office Director was informed that additional documentation maybe needed. No deficiencies cited during todays visit. Exit interview completed with Business Office Manager - Narissa Rodriguez. A copy of this report was provided for facility records.the state’s words, verbatim · CDSS document, Dec 23, 2025

Type of visit: Case Management - Other

On 08/15/2025, Licensing Program Analyst (LPA) M Vega arrived at the facility unannounced visit to provide updated license to facility. LPA was greeted by receptionist and stated the purpose of the visit. LPA met with Executive Director (ED) - Emily Venegas. LPA provided updated license to facility. Old license was recovered by LPA to be returned to RO. No deficiencies issued during this visit. A copy of this report was given to the Executive Director (ED) - Emily Venegas, whose signature on this form confirm receipt of this report.the state’s words, verbatim · CDSS document, Aug 15, 2025

Allegation investigated: Licensee does not ensure that staff has a criminal clearance

On June 17, 2025, Licensing Program Analyst (LPA) M Vega conducted an unannounced inspection at the facility and met with Executive Director (ED) - Emily Venegas. The purpose of the visit was to open a complaint investigation and deliver findings regarding the above allegation. It was alleged that the facility Licensee does not ensure that staff has a criminal clearance. Based on record review it has been determined that the facility does ensure that staff has a criminal clearance, it is determined the allegation is unfounded. This agency has investigated the complaint alleging “Licensee does not ensure that staff has a criminal clearance” We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened or is without a reasonable basis. We have found that the complaint was unfounded, therefore we have dismissed the complaint. Unfounded No deficiencies were observed and cited during this visit. Exit interview conducted. A report was signed, and a copy of this report was provided for facility records.the state’s words, verbatim · CDSS document, Jun 17, 2025 · control 24-AS-20250612152957

Allegation investigated: Staff are not permitting resident to leave the facility

Licensing Program Analyst (LPA) M Vega conducted a case management investigation visit to the facility. During the course of this investigation LPA reviewed facility files relevant to the complaint investigation. It was determined that the above allegation: Staff are not permitting resident to leave the facility is UNFOUNDED. Resident 1 (R1) and residents are permitted to leave facility under the supervision for resident safety. R1 during investigation was out with family member, documented proof demonstrates multiple outings. Other residents were on a field trip outside the facility as well. Staff 1 (S1) demonstrated the check in and check out process for residents and responsible party. This agency has investigated the complaint alleging (Staff are not permitting resident to leave the facility). We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis therefore we have dismissed the complaint. Unfoundedthe state’s words, verbatim · CDSS document, Apr 21, 2025 · control 24-AS-20250204154917

Type of visit: Required - 1 Year

On 04/21/2025, Licensing Program Analyst (LPA) M Vega arrived at the facility unannounced to conduct Required Annual Inspection. LPA was greeted by receptionist and stated the purpose of the visit. LPA met with Executive Director (ED) - Emily Venegas. LPA conducted tour of facility with ED. Residents were observed thought the facility, some residents were in room 118 and room 143 playing bingo. Residents also observed in room 140 watching television, other residents were walking some siting in different parts of the facility. Other residents were observed to be coming back from a trip outside the facility. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 7/11/2024. Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer, walk-in refrigerator, and pantry. Refrigerator temperature was maintained at 32 degree F. and freezer was maintained at 0 degree F. LPA toured a sample of resident bedrooms. Residents' rooms were observed with adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested at 114.9 degrees F. LPA observed securely fastened grab bars and non-skid mat in all shower areas. Medications were stored in a locked medication room in a medication cart. Medications records were reviewed in Electronic Filing system. First Aid Kit was stored in medication room and observed with all required items. LPA toured laundry room and observed chemicals were stored and locked. Continuation on LIC 809C Facility courtyard was toured and observed to be free from debris. There was outdoor seating available for the residents. A sample of residents’ files were reviewed to have updated emergency contact, Admission agreement, Needs and Services Plan and Pre-Appraisal Plan. A sample of staff files were reviewed. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel record. Staff are fingerprinted clear and associated to the facility. An exit interview was conducted with the ED. The following documents are requested and submitted to Fresno CCL by: 05/02/25 : LIC 308 Designation of Facility Responsibility LIC 500 Personnel Report LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly LIC 9020 Register of Facility Clients/Residents Copy of current Administrator Certificate No deficiencies issued during this inspection. A copy of this report was given to the Executive Director (ED) - Emily Venegas, whose signature on this form confirm receipt of this report.the state’s words, verbatim · CDSS document, Apr 21, 2025

Type of visit: Case Management - Incident

Case management made out to the facility due to received incident report from facility regarding medication errors with residents and caregiver involved with the incident. Discussed with Executive Director (ED) - Emily Venegas concerns involving this matter. Executive Director (ED) - Emily Venegas did provide documentation of Training conducted with staff right after the incident occurred. Records do show past incidents of medication, ED stated that there is zero tolerance policy for medication errors. Since incident reported to CCL staff person has been put on notice. Facility has taken steps to prevent medication errors, resident was monitored and there were no adverse reactions reported. LPA M Vega discussed the issue with Executive Director. No deficiencies cited at this time since facility and facility personnel took the necessary and crucial steps in ensuring proper resident care and supervision. Resident doctors were notified along with resident responsible parties with incidents and was well documented and sent into CCL by appropriate due date of reporting time frames. Follow up has been done with resident doctors as well.the state’s words, verbatim · CDSS document, Apr 21, 2025

Type of visit: Case Management - Incident

LPA M Vega conducted case management visit to follow-up on an incident report submitted to licensing,LPA spoke with Executive Director - Emily Venegas about incident, in which it was reported that Client #1 was administered a medication during the PM medication pass. Staff #1 reported this immediately and the client's Physician was notified. Client was placed on observation with no issues observed. Resident's responsible party was also notified. Kayleen - Regional Nurse stated that Staff #1 was was disciplined and retrained on medication administration. Kayleen (RN) stated that staff is has taken this additional in person training. Resident was not reported to have had any adverse reactions. Copy of training was provided to LPA. No deficiencies were cited because immediate and appropriate action was taken. A copy of this report was provided to Executive Director.the state’s words, verbatim · CDSS document, Jan 9, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) M Vega arrived unannounced to conduct a Case Management visit on 11/26/2024. LPA met with facility front desk Staff 1 (S1), Executive Director Kayleen August was contacted and arrived a few minutes later, Stated the purpose of visit to Executive Director Kayleen August. LPA served Decision and Order excluding Staff 2 (S2) from being present inside the facility. LPA requested a current and updated Personnel Report (LIC 500) and Guardian account be updated to remove S2 from the facility staff roster. A notice of completion shall be submitted to Community Care Licensing (CCL). LPA informed Executive Director Kayleen August that S2 is not allowed to be employed and/or on any facility premises. The Decision and Order of Exclusion From All Facilities came into effect as of 11/25/2024 upon receipt of the letter. A copy of the letter was given to facility Executive Director Kayleen August during this visit. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed and cited. Exit interview held with Executive Director Kayleen August, A Copy of report given.the state’s words, verbatim · CDSS document, Nov 26, 2024

Allegation investigated: Staff is not correctly administering medications

On 10/04/2024 Licensing Program Analyst (LPA) M Vega arrived unannounced to deliver findings on the above allegations. LPA met with Sarah Dennis - Executive Director and Samantha Keith - Director of Resident Services, stated the purpose of the visit. Allegation: Staff is not correctly administering medications. Based on observation and records review R1 received medication as listed in Central Medications Records Log. LPA requested to review medications. Samantha Keith reviewed medications with LPA. Per review no issues with medication found. Although these allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. A copy of the report was provided to the licensee, No deficiencies issued, exit interview conducted. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 4, 2024 · control 24-AS-20240823132720

Allegation investigated: Staff do not ensure resident’s catheter is properly maintained.

On 10/04/2024 Licensing Program Analyst (LPA) M Vega arrived unannounced to deliver findings on the above allegations. LPA met with Sarah Dennis - Executive Director and Samantha Keith - Director of Resident Services, stated the purpose of the visit. Allegation: Staff do not ensure resident’s catheter is properly maintained. LPA conducted interview with R1 observed R1 ambulating and with no hose that would pose fall risk. Reviewed records for R1: Based on R1 facility notes, the monitoring of catheter is recorded. R1 Service Plan also indicates that, R1 has been on home health since admission. Although these allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. A copy of the report was provided to the licensee, No deficiencies issued, exit interview conducted. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 4, 2024 · control 24-AS-20240827154040

Allegation investigated: Staff keep resident's restrooms locked. Staff are not providing residents with adequate food portions. Staff are not providing residents drinking water. Staff do not ensure resident's grooming needs are being met. Staff are not providing residents with activities.

On 09/26/2024, Licensing Program Analyst (LPA) V. Gorban visited the facility to deliver findings. During this visit LPA met with Samantha Keith Director of Resident Services, stated the purpose of the visit. During this visit LPA toured the facility inside and out, observed clients in care, and discused allegations with DRS. Allegation: Staff keep resident's restrooms locked. Based off observations and interviews on 7/18/24 during facility visit resident’ s room restrooms checked and found unlocked for use. Allegation: Staff are not providing residents with adequate food portions. Based of observation, staff interview and records review R1 received three meals a day and additionally provided regular snacks which were documented by facility staff. Report continues on attached LIC9099-C Unsubstantiated Allegation: Staff are not providing residents drinking water. Facility staff documented regular checks on R1 and also maintained a hydration log. Hydration checks were conducted every hour. Allegation: Staff do not ensure resident's grooming needs are being met. Based of staff interviews and observation and records review during the visit on 7/18/24 the facility provided shower to residents as scheduled. Allegation: Staff are not providing residents with activities. Based of records review facility providing daily activities to residents in care. During the facility visit and observation on 7/18/24 R1 was offered and refused to attend activity that day. The facility activities schedule is updated weekly and posted on the wall in main hallway for review for visitors. Although these allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. A copy of the report was provided to the licensee via email and exit interview conducted.the state’s words, verbatim · CDSS document, Sep 26, 2024 · control 24-AS-20240718061012

Type of visit: Case Management - Incident

On 5/21/2024, Licensing Program Analyst (LPA) V Gorban visited the facility to conduct case management to he incident that occurred on 5/11/2024 with resident (R1). During this visit LPA met with Administrator, Sarah Denis stated the purpose of the visit. During this visit LPA toured the facility conducting safety check and interviewed staff and Administrator. Based on incident report provided to Licensing on 5/17/24, R1 increased lethargy and decreased in responsiveness. Per report, based on that observation the facility contacted responsible party at 1645. Per report, responsible party did not agree to sent R1 out for evaluation. Per report, at 17:37 EMS was assessing R1 at the facility. During this visit LPA requested additional facility files for review. No deficiency was cited during this visit Exit interview conducted, report signed and copy provided for facility records.the state’s words, verbatim · CDSS document, May 21, 2024

Type of visit: Required - 1 Year

On 04/03/2024, Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct Required Annual Inspection. LPA was greeted by receptionist and stated the purpose of the visit. LPA met with Administrator (AD) Sarah Dennis, certification number 6050734740 and expiration date 2/04/2025. LPA conducted tour of facility with AD. Residents were observed at the facility during breakfast and in common areas. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 006/06/2023. Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer, walk-in refrigerator, and pantry. Food is delivered twice a week on Mondays and Thursdays. Refrigerator temperature was maintained at 32-degree F. and freezer was maintained at 0-degree F. LPA toured a sample of resident bedrooms. Residents' rooms were observed with adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested at 106 degrees F. LPA observed securely fastened grab bars and non-skid mat in all shower areas. Medications were stored in a locked medication room in a medication cart. Medications records were reviewed in AugustHealth. First Aid Kit was stored in medication room and observed with all required items. LPA toured laundry room and observed chemicals were stored and locked. Facility courtyard was toured and observed to be free from debris. There was outdoor seating available for the residents. Report continues on LIC809-C A sample of residents’ files were reviewed to have updated emergency contact, Admission agreement, Needs and Services Plan and Pre-Appraisal Plan. A sample of staff files were reviewed. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel record. Staff are fingerprinted clear and associated to the facility. An exit interview was conducted with the AD. The following documents are requested and submitted to Fresno CCL by: 04/10/24 : · LIC 308 Designation of Facility Responsibility · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly · LIC 9020 Register of Facility Clients/Residents · Copy of current Administrator Certificate · Alternate contact information including name, telephone number, & email address. No deficiencies issued during this inspection. A copy of this report was given to the AD, whose signature on this form confirm receipt of this report.the state’s words, verbatim · CDSS document, Apr 3, 2024

Type of visit: Case Management - Incident

On 02/26/24, Licensing Program Analyst (LPA) V Gorban conducted a case management deficiency visit to the facility. LPA introduce self, stated the purpose of the visit, and met with Samantha Keith, Director of Resident Services. The purpose of the visit is to address an incident that occurred where R1 went AWOL on 02/17/24. The facility was unaware when R1 AWOL the facility. Residents file review stated resident is dementia and unable to leave facility unassisted. Therefore, as a result, a deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached 809D. An exit interview was conducted. A copy of this report and appeal rights was provided to Director of Resident Services, whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, Feb 26, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87413(a)(2) · Plan of correction due date: Feb 27, 2024

87413(a) In each facility (2) Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice. This requirement was not met as evidenced by: Based on interview and record review, staff did not provide care and supervision when memory care R1 left the facility unsupervised on 02/17/24 at unknown time or approximately 8:38 PM. The facility was not aware R1 went AWOL until approximately at 10:15 PM Fresno PD notified the facility. This is poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 26, 2024

Plan of correction: Administrator and Director of Resident Services offered to provide staff training / in-service, also ensure that facility doors are locked and secured correctly. Deficiency was cleared at the time of the visit.

Type of visit: Case Management - Incident

On 01/04/2024, Licensing Program Analyst (LPA) Gorban conducted a case management in response to incident report regional office received on 09/14/23. LPA Gorban met with facility Administrator Sarah Dennis, stated the purpose of the visit, and was allowed entry into the facility. During this visit LPA Gorban toured the facility inside and out, observed residents in care and reviewed residents’ facility files. LPA discussed with administrator following. Based on department file review facility failed in timely manner, following Title 22, to notify Licensing within seven days incident occurred. Continuation of this report will be issued during this visit on LIC809-D. Exit interview conducted. Report signed and a copy of this report with appeal rights provided to administrator for facility records.the state’s words, verbatim · CDSS document, Jan 4, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jan 5, 2024

87211 Reporting Requirements. (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 below. This was not observed as evidenced by: Facility failed to submit incident report in timely manner to Licensing, which posses potential safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 4, 2024

Plan of correction: By plan of correction facility will ensure to review and follow title 22, reporting requirements and submit to LPA by email written statement 01/05/24.

Allegation investigated: Staff did not assist resident with obtaining medical care

On 12/28/23 Licensing Program Analyst (LPA) V Gorban visited facility stated above to deliver findings. LPA met with Director of Resident Services, Samantha Keith, explained the purpose of the visit. LPA toured facility inside and out, observed residents in care and discussed findings to allegations. Administrator was notified of Licensing visit. Allegation: Staff did not assist resident with obtaining medical care. During this investigation LPA reviewed facility records, interviewed staff, and Administrator. Facility records and witnesses confirmed that medical care was provided to resident in need. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted, no citations were issued during this visit. Visit report signed and copy of this report provided for facility records. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 28, 2023 · control 24-AS-20231002141122

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.