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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206814
Report Date: 11/26/2024
Date Signed: 11/26/2024 04:01:48 PM

Document Has Been Signed on 11/26/2024 04:01 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:COPPER RIVER RETIREMENT GROUP/SHEAFACILITY NUMBER:
107206814
ADMINISTRATOR/
DIRECTOR:
CHRIS CONROYFACILITY TYPE:
740
ADDRESS:2617 E. SHEA DRIVETELEPHONE:
(559) 325-7383
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
11/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator - Shay AyersTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 11/26/2024, Licensing Program Analyst (LPA) M Vega 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 by Staff 1 (S1). Administrator (AD) Shay Ayers was notified of Licensing visit over the phone and was able to attend the visit. AD certification number 6033549740. LPA toured facility with AD Shay Ayers

The facility was observed to be at a comfortable temperature, of 71 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 most residents in common area after lunch playing bingo, others in their rooms resting. Department phone number and infection prevention information signs were posted in facility.

LPA toured facility with Administrator outside. LPA observed pool in the back yard, fenced and the pool gate was locked. Outdoor seating area was observed in good repair and available to residents.

Fire extinguisher was observed with a service date of 07/22/2024. All 6 residents’ bedrooms were observed to be with comfortable temperature. Kitchen water temperature was tested and recorded reading of 117.6 degrees F.
Medications observed to be locked in closet near front entry to facility. LPA reviewed medication records maintained and accurate as of inspection. Cleaning supplies were observed to be in a locked and inaccessible to residents cabinet in garage. 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.

Continued on LIC 809C
Brenda ChanTELEPHONE: (650) 272-4781
Martin VegaTELEPHONE: 559-243-8080
DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: COPPER RIVER RETIREMENT GROUP/SHEA
FACILITY NUMBER: 107206814
VISIT DATE: 11/26/2024
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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) 272-4781
LICENSING EVALUATOR NAME: Martin VegaTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC809 (FAS) - (06/04)
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