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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206811
Report Date: 01/22/2024
Date Signed: 01/27/2024 09:41:30 PM


Document Has Been Signed on 01/27/2024 09:41 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: 6DATE:
01/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:19 AM
MET WITH:Licensee- Shay AyersTIME COMPLETED:
01:45 PM
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On 1/22/24 Licensing Program Analyst (LPA) B. Miranda conducted an unannounced Required - 1 Year Annual. LPA explained the reason for the visit and Licensee Shay Ayers was contacted and arrived shortly after.

LPA toured the facility inside and out to include entry, kitchen, dining, living room, bedrooms, bathrooms, and exterior. All fire exit routes have a clear pathway but have an additional door flip lock which creates an obstruction. Facility will provide verification of clearance by end of business day 1/29/24 Medications are stored in a locked closest in the facility. Toxins, cleaning supplies, knives and sharp objects are secured and inaccessible to residents.

Facility is at maximum capacity with 6 residents each having their individuals rooms. LPA observed the facility to be clean, free from clutter, and odor free. First aid kit is complete. LPA observed supply of Personal Protective Equipment (PPE).

Fire extinguishers have been services as of 07/28/23 and are in good standing. Smoke alarms and carbon monoxide reader was tested and in working condition. Water temperature was checked in the bathroom and read at 105.3 degree Fahrenheit.

LPA reviewed a sample of employee files which are current and up to date with training. LPA observed a sample of resident's charts which are current. Liability insurance is current and up to date.

Citation was not issued at this time, if facility is not able to provide verification citation will be issued at a later date.
Exit interview was conducted and a copy of this report LIC809 were provided to Licensee Shay Ayers.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 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.

LIC809 (FAS) - (06/04)
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