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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206811
Report Date: 12/09/2022
Date Signed: 12/09/2022 01:47:49 PM


Document Has Been Signed on 12/09/2022 01:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Licensee- Shay Dustin & Administrator- Clinton Arciete TIME COMPLETED:
11:40 AM
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On 12/9/21 at 10:05 AM, Licensing Program Analyst (LPA) B. Miranda arrived unannounced to conduct an annual inspection. LPA was met by staff and stated purpose of visit. LPA was granted entry. Licensee (LIC) Shay Dustin and Administrator (AD) Clinton Arciete arrived a short time later.

LPA toured the facility inside and out. 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 resident's medications and observed the months supply. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health. Resident’s files have updated emergency contact information. Administrator certification is current.
Kitchen was observed as clean and free of clutter. Fire extinguisher is up to date on service and in good standing. Water temperature read at 109.9 degrees Fahrenheit.

LPA observed outside was clear and free from obstruction.

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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
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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