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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209092
Report Date: 11/06/2020
Date Signed: 11/06/2020 01:53:41 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:COPPER RIVER RETIREMENT GROUP - BUCHANANFACILITY NUMBER:
107209092
ADMINISTRATOR:AYERS, LA SHAYFACILITY TYPE:
740
ADDRESS:232 OMAHA AVETELEPHONE:
(559) 396-9302
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY:6CENSUS: 0DATE:
11/06/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Shay DustinTIME COMPLETED:
02:16 PM
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On or about today's date and due to the Covid-19, LPA, Les Xiong did a televisit inspection at the above facility for an announced Pre-licensing visit. LPA met with Administrator, La Shay Ayers "Shay Dustin".

Administrator cell phone: 559-396-9302, email: shay.copperriver@gmail.com.

LPA televisit was conducted for the above facility. Common rooms have adequate furnishings and lighting. All of the resident bedrooms have adequate lighting. Hot water temperature in bathrooms measured at 110 degrees. LPA observed a supply of extra bed linens and personal hygiene and grooming products. Kitchen observed with adequate amount of perishable and non-perishable food. Cleaning supplies and knives will be stored in a locking cabinets. Medications will be kept in a locked cabinet. First aid kit contains all the required items. A fire extinguisher is present and up to date. Smoke detectors/carbon monoxide were present and functional.

Outside of the facility toured. No hazards were observed.

Component 3 orientation was conducted during this visit. All required postings are posted.

I have found that applicant has met all pre-licensing requirements. LPA will submit the application for further processing.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Les XiongTELEPHONE: (559) 410-1772
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020
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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