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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 01:59:19 PM


Document Has Been Signed on 12/09/2022 01:59 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:41 AM
MET WITH:Licensee- Shay DustinTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) B. Miranda met with Licensee Shay Dustin. LPA asked Licensee if S2 was still working at the facility. Licensee stated S2 is still associated but has not worked at the facility for over 2 years. LPA asked if a noticed was received about S2 being an exclusion for the facility. Licensee stated no but someone called and left voicemail.

Licensee stated she will disassociate S2 from all facilities by today 12/9/2022

No other action to be taken at this time.

Exit interview conducted and report will be emailed to Licensee Shay Dustin.
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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