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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206811
Report Date: 01/14/2022
Date Signed: 01/14/2022 06:56:13 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/26/2021 and conducted by Evaluator Malia Thao
COMPLAINT CONTROL NUMBER: 24-AS-20211026095919
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: 6DATE:
01/14/2022
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Shay Dustin, LicenseeTIME COMPLETED:
05:10 PM
ALLEGATION(S):
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Staff mismanaged resident's medication.
Resident did not receive a proper refund.
INVESTIGATION FINDINGS:
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On 1/14/22 at 2:35 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to deliver findings. LPA explained reason for inspection and was granted entry. Licensee (LIC) Shay Dustin arrived a short time later.

During the course of the investigation, LPA conducted interviews, reviewed records, and made observations. Based on observations, interviews, and records review, LPA found that staff mismanaged resident's medication and resident did not receive a proper refund. R1's physician report did not order for R1's medication to be crushed or placed in R1's food. According to R1's admission agreement section VI(A)(1)(b)(2), since R1 left the facility during the first month of residency, R1 is entitled to 80% of the preadmission fee. Therefore, the above allegations are substantiated.

Continue on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/26/2021 and conducted by Evaluator Malia Thao
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20211026095919

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: 6DATE:
01/14/2022
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Shay Dustin, LicenseeTIME COMPLETED:
05:10 PM
ALLEGATION(S):
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9
Resident sustained a pressure injury while in care.
Staff did not meet resident's hygiene needs.
Staff did not safe guard resident's personal items.
INVESTIGATION FINDINGS:
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On 1/14/22 at 2:35 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to deliver findings. LPA explained reason for inspection and was granted entry. Licensee (LIC) Shay Dustin arrived a short time later.

During the course of the investigation, LPA conducted interviews, reviewed records, and made observations. Based on observations, interviews, and records review, there was not sufficient evidence to show resident sustained a pressure injury while in care, staff did not meet resident's hygiene needs, or that staff did not safe guard resident's personal items. The above allegations are unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted. Due to COVID-19 precautionary measures, a copy of this report was emailed to email on record with "Read receipt" to confirm receipt of this report. LPA confirmed email on record is correct with Licensee.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/26/2021 and conducted by Evaluator Malia Thao
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20211026095919

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: 6DATE:
01/14/2022
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Shay Dustin, LicenseeTIME COMPLETED:
05:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not meet resident's dietary needs.
Staff cut resident's hair without conservator's consent.
INVESTIGATION FINDINGS:
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13
On 1/14/22 at 2:35 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to deliver findings. LPA explained reason for inspection and was granted entry. Licensee (LIC) Shay Dustin arrived a short time later.

During the course of the investigation, LPA conducted interviews, reviewed records, and made observations. This agency has investigated the complaint alleging staff did not meet resident's dietary needs and that staff cut resident's hair without conservator's consent. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

Exit interview conducted. Due to COVID-19 precautionary measures, a copy of this report was emailed to email on record with "Read receipt" to confirm receipt of this report. LPA confirmed email on record is correct with Licensee.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 24-AS-20211026095919
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 01/14/2022
NARRATIVE
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Continued from LIC9099.


Deficiencies are being cited based on LPA observations, interviews conducted, and records review in accordance with the California Code of Regulations, Title 22, see LIC9909D.

Exit interview conducted. Due to COVID-19 precautionary measures, a copy of this report and appeal rights were emailed to email on record with "Read receipt" to confirm receipt of this report. LPA confirmed email on record is correct with Licensee.

SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 24-AS-20211026095919
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/21/2022
Section Cited
CCR
87465(a)(5)
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87465 Incidental Medical and Dental Care (a) (a) A plan for incidental medical and dental care shall be developed by each facility...(5) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
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Licensee will submit proof of a plan to ensure crush orders are appropriately addressed during the admission intake, to CCL by POC due date.
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R1's physician report did not order for R1's medication to be crushed or placed in R1's food. This poses a potential health, safety, or personal rights risk to residents in care.
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Type B
01/21/2022
Section Cited
CCR
87507(f)
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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 was not met as evidenced by:
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Licensee will submit proof of a plan on how refunds will be addressed with residents and resident's responsible party following termination and proof of certified mail and check refund paid to R1 in the amount of $933.39, to CCL by POC due date.
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According to R1's admission agreement section VI(A)(1)(b)(2), since R1 left the facility during the first month of residency, R1 is entitled to 80% of the preadmission fee. This poses a potential personal rights risk to residents in care.
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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: 01/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5