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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206811
Report Date: 11/02/2021
Date Signed: 11/02/2021 11:08:42 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:COPPER RIVER RETIREMENT GROUPFACILITY NUMBER:
107206811
ADMINISTRATOR:APOLINARIO P PEREZFACILITY TYPE:
740
ADDRESS:1115 E. PINEHURSTTELEPHONE:
(559) 433-0488
CITY:FRESNOSTATE: CAZIP CODE:
93730
CAPACITY:6CENSUS: 4DATE:
11/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Shay Dustin, Licensee
Paula Cubangbang, Administrator		TIME COMPLETED:
11:10 AM
NARRATIVE
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On 11/2/21 at 8:45 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an annual inspection. LPA was met by staff and stated purpose of visit. LPA was granted entry. Administrator (ADM) Paula Cubangbang and Licensee (LIC) Shay Dustin arrived a short time later.

A tour of the facility was conducted. COVID-19 guidelines are in place. Facility has one main entrance/exit point. Facility was observed clean and without any obstructions or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked and no residents share a room. LPA checked residents’ medications and observed the month's supply. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health. Residents files have updated emergency contact information. Administrator certification is current.

The following deficiency was observed:

1. R1's hospital bed observed with two half length bed rails. One from head half length of bed and one from foot half length of bed.

Deficiency is being cited based on LPA observations, record review, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

Exit interview conducted. A copy of this report and appeal rights were discussed and emailed to email on record with "Read receipt" to confirm receipt of this report.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: COPPER RIVER RETIREMENT GROUP
FACILITY NUMBER: 107206811
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, interview, and record review, the licensee did not comply with the section cited above. R1's hospital bed observed with two half length bed rails. One from head half length of bed and one from foot half length of bed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2021
Plan of Correction
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Licensee had foot half length bed rail removed during inspection. POC cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021
LIC809 (FAS) - (06/04)
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