107209092-11-4-2021-24-AS-SPIY-C8PQBS-20211112110159

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107209092
Report Date: 10/15/2021
Date Signed: 11/04/2021 12:10:00 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/23/2021 and conducted by Evaluator Les Xiong

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20210423082729

FACILITY NAME:	COPPER RIVER RETIREMENT GROUP - BUCHANAN		FACILITY NUMBER:	107209092
ADMINISTRATOR:	AYERS, LA SHAY		FACILITY TYPE:	740
ADDRESS:	232 OMAHA AVE		TELEPHONE:	(559) 396-9302
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93619
CAPACITY:	6	CENSUS: 5	DATE:	10/15/2021
		UNANNOUNCED	TIME BEGAN:	08:39 AM
MET WITH:	La Shay Ayers		TIME COMPLETED:	10:10 AM

ALLEGATION(S):

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Facility failed to issue a refund

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) L. Xiong conducted the subsequent complaint investigation visit to the facility. I met with La Shay Ayers, Administrator and informed her the purpose of visit. During the course of this complaint investigation LPA interviewed staff and obtained and/or reviewed facility records. It was determined based on the interviews and records review that the above allegation is SUBSTANTIATED. Facility failed to issue a refund. It was discovered that the refund policy was not in complaince with title 22, a refund was made and refund policy was amended. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.”)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Les Xiong	TELEPHONE: (559) 410-1772
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20210423082729

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 - BUCHANAN	FACILITY NUMBER: 107209092
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/15/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/22/2021 Section Cited HSC 1569.652	1 2 3 4 5 6 7	Health and Safety Code 1569.652 (c) Procedure upon death of resident. (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual... contractually responsible for the fees... within 15 days after the personal property is removed. This requirement was not met as evidenced by: Based on interviews, facility failed to issue a full refund. This posed a potential risk or (an immediate risk) to the health, safety and/or personal rights of clients in care.	1 2 3 4 5 6 7	When the problem was discovered, Adm. Shay Ayers sent the responsible party the full refund. No further correction needed.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Les Xiong	TELEPHONE: (559) 410-1772
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

LIC9099 (FAS) - (06/04)

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