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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206814
Report Date: 11/01/2023
Date Signed: 11/05/2023 08:12:10 PM


Document Has Been Signed on 11/05/2023 08:12 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/SHEAFACILITY NUMBER:
107206814
ADMINISTRATOR:CHRIS CONROYFACILITY TYPE:
740
ADDRESS:2617 E. SHEA DRIVETELEPHONE:
(559) 325-7383
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:6CENSUS: 6DATE:
11/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator, Shay AyersTIME COMPLETED:
11:45 AM
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On 11/01/2023, Licensing Program Analyst (LPA) V. Gorban arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility. LPA toured facility with staff Thelma. Administrator (AD) Shay Ayers was notified of Licensing visit over the phone and was able to attend the visit. AD certification number 6033549740.

Facility has one entrance/exit point. LPA toured facility with Administrator inside and out. Facility pool serviced weekly. LPA observed pool in the back yard, fenced and the pool gate locked for residents safety.
The facility was observed to be at a comfortable temperature, of 77 degrees F. Facility is free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. LPA observed some residents in common area after breakfast watching television, others in their rooms resting. Department phone number and infection prevention information signs were posted thought the facility.
Inspecting kitchen LPA observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. An emergency disaster supply was observed.

Fire extinguisher was observed with a service date of 07/28/2023. All 6 residents’ bedrooms were observed to be with comfortable temperature. Bathroom water temperature was tested and recorded reading of 105 degrees F.
Medications observed to be locked in a cabinet in the kitchen. LPA reviewed medication records appears to be administered properly. Cleaning supplies were observed to be in a locked cabinet in the laundry room. An outdoor seating area was observed operational for residents in care.
LPA reviewed Staff and Resident files. Resident files observed to have updated information.

No deficiencies were observed and cited. Exit interview conducted.
Report was signed and copy of this report was provided for facility records.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023
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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