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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206815
Report Date: 11/20/2024
Date Signed: 11/20/2024 03:28:40 PM

Document Has Been Signed on 11/20/2024 03:28 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/EVERGLADEFACILITY NUMBER:
107206815
ADMINISTRATOR/
DIRECTOR:
APOLINARIO P PEREZFACILITY TYPE:
740
ADDRESS:272 W. EVERGLADETELEPHONE:
(559) 325-2273
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
11/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Administrator - Shay AyersTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 11/20/2024, Licensing Program Analyst (LPA) M Vega arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduce self to Staff 1 (S1), stated the purpose of the visit, and was granted entry to the facility, Administrator was called over the phone and arrived few minutes later. LPA toured facility with Administrator (AD) Shay Ayers. AD certification number 6033549740.

The facility was observed to be at a comfortable temperature, of 70 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 lunch watching television, others in their rooms resting. Department phone number and infection prevention information signs were posted thought the facility.

LPA observed rooms for residents were properly furnished, Clean and in good repair. All residents’ bedrooms were observed to be with comfortable temperature.

LPA inspected outside the facility and pool area secured with fence and locked at time of inspection. There was shaded seating for residents as well and in good repair. No obstructions to fire exits.

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 07/22/2024.

Continuation LIC 809C

Brenda ChanTELEPHONE: (650) 272-4781
Martin VegaTELEPHONE: 559-243-8080
DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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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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/EVERGLADE
FACILITY NUMBER: 107206815
VISIT DATE: 11/20/2024
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Medications observed to be locked in hallway area. LPA reviewed medication records to be accurate at the time of inspection. Cleaning supplies were observed to be in a locked cabinet in the laundry room.

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: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC809 (FAS) - (06/04)
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