107206811-12-23-2024-24-AS-KKAR-DC8U6G-20241223141819

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107206811
Report Date: 12/23/2024
Date Signed: 12/23/2024 02:18:27 PM

Document Has Been Signed on 12/23/2024 02:18 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 GROUP		FACILITY NUMBER:	107206811
ADMINISTRATOR/ DIRECTOR:	APOLINARIO P PEREZ		FACILITY TYPE:	740
ADDRESS:	1115 E. PINEHURST		TELEPHONE:	(559) 433-0488
CITY:	FRESNO	STATE: CA	ZIP CODE:	93730
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	12/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Licensee Shay Ayers		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/23/2024 Licensing Program Analyst (LPA) K.Kaur arrived at facility unannounced to complete an Annual inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Direct Care Staff, Clinton Arciete. Licensee/ Administrator Shay Ayers was contacted and arrived a short time later. The facility has 5 residents, of which all were present during the inspection. LPA toured the facility with the Administrator. Tour started in the kitchen. Knives were locked in the kitchen cabinet. LPA observed a 7-day supply of non-perishable foods and 2-day supply of perishable foods. Cleaning supplies observed locked in the cabinet under the kitchen sink. The dining room is equipped with a table and chairs, the living room is equipped with adequate sofas and recliners for seating. Medications, first aid kit observed locked in the hallway closet. Residents' bedrooms were observed to be adequately furnished with beds, dresser, and adequate lighting. Mattresses and linen were in good condition. At 12:33 PM LPA observed one of the resident’s window screen frame was bent. The laundry area toured and observed with locks on all cabinets. Extra linen and towels are available in the hallway closet. LPA observed grab bars installed by toilet and non-skid mats in place. Smoke alarm detectors and Carbon monoxide detectors installed and operational. Adequate outside space for rest and recreational. Sufficient seating observed under a covered patio. The fire extinguisher in kitchen was serviced July 22, 2024. Backyard gate is self-closing and self-latching. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report and ID Documentation. Medication reviewed. Staff files were reviewed for good health. At 1:43 PM LPA observed one of the resident’s physician’s report was not signed by a physician. Staff files had health screenings/ TB Clearance. It was verified that current staff on duty are CPR certified. Last Fire Drill conducted in September 2024.. Continued to 809C...

See Moua	TELEPHONE: (559) -58-4596
Kamaldeep Kaur	TELEPHONE: 559-243-8080
	DATE: 12/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024

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 12/23/2024 02:18 PM - 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: 12/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one out of one resident's bedroom window sceen frame was bent which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/30/2024
	Plan of Correction
1 2 3 4	Administrator agrees to replace window screen and submit pictures/ receipt of repairs by due date.

Section Cited

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, the licensee did not comply with the section cited above in 1 out of 5 resident's current physicans report was not signed by a physician which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/30/2024
	Plan of Correction
1 2 3 4	Administrator agrees to have physician sign the report and send proof by due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

See Moua	TELEPHONE: (559) -58-4596
Kamaldeep Kaur	TELEPHONE: 559-243-8080
	DATE: 12/23/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

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
	VISIT DATE: 12/23/2024

NARRATIVE

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Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 12/30/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020.

An exit interview was conducted with Licensee. Report signed on-site; a copy of this report, 809D with appeal rights was provided via email due to technical difficulties.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024

LIC809 (FAS) - (06/04)

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