107206811-1-27-2024-24-AS-BCHN-D2DVY7-20240212155038

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107206811
Report Date: 01/22/2024
Date Signed: 01/27/2024 09:39:27 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/30/2023 and conducted by Evaluator Brianna Miranda

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20230830134334

FACILITY NAME:	COPPER RIVER RETIREMENT GROUP		FACILITY NUMBER:	107206811
ADMINISTRATOR:	APOLINARIO P PEREZ		FACILITY TYPE:	740
ADDRESS:	1115 E. PINEHURST		TELEPHONE:	(559) 433-0488
CITY:	FRESNO	STATE: CA	ZIP CODE:	93730
CAPACITY:	6	CENSUS: 6	DATE:	01/22/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Licensee Shay Ayers		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Financial Abuse

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 01/22/2024 Licensing Program Analyst (LPA) 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. LPA met with Licensee Shay Ayers.
LPA conducted a walk around tour of the facility inside and out and verify there was no immediate danger.
1. The Department investigated the allegation: Financial Abuse. Interviews were conducted between resident and staff member. LPA also reviewed records of charges that cleared and declined, admissions agreement, and R1's physician 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 LIC9099 was provided to Licensee Shay Ayers.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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