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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206811
Report Date: 03/20/2024
Date Signed: 03/20/2024 11:27:50 AM


Document Has Been Signed on 03/20/2024 11:27 AM - 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:
03/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shay AyersTIME COMPLETED:
11:45 AM
NARRATIVE
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On 3/20/2024 Licensing Program Analyst B. Miranda arrived at the facility unannounced to conduct a case management. LPA introduced herself and requested to speak with the Administrator. Shay Ayers was contacted and arrived shortly after.

LPA explained this was a follow up visit from the annual inspection on 1/22/2024 regarding the door flip locks on various exits throughout the facility. LPA previously explained the flip locks are not allowed unless it was previously cleared by the Fire Dept. As of today 3/20/24, no verification was provided to the Dept verifying the flip locks being cleared to use. LPA observed all flip locks to have been removed. Due to locks originally being on the exits doors during the annual inspection citation was issued for deficiency. Citation was issued under Title 22, Division 6, Chapter 8 on LIC809D form.

Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Shay Ayers

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
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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Document Has Been Signed on 03/20/2024 11:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 GROUP
FACILITY NUMBER: 107206811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2024
Section Cited
CCR
87202(a)(1)(2)

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87202 Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
(1) Non ambulatory persons.
(2) Bedridden persons
This requirement is not met as evidenced by:
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On 3/20/24 LPA observed all flip locks to have been removed and POC will be cleared.
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Based on observation, interview, and record review on 1.22.24 the licensee failed to maintain a fire clearance. LPA observed door flip locks on all exit routes which included front door, back door, garage door leading to outside, and one on the outside of R1’s room. This creates a obstruction when trying to exit during an emergency. This poses an immediate health, safety, or 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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2