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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209092
Report Date: 11/04/2021
Date Signed: 11/12/2021 10:01:23 AM

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: 4DATE:
11/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:La Shay AyersTIME COMPLETED:
11:43 AM
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Today, Licensing Program Analyst L. Xiong arrived at the facility unannounced to conduct the Infection Control Inspection. LPAs met Administrator, La Shay Ayers and inform her the purpose of the visit. LPA completed the Covid-19 Contact questionnaire prior to entrance into the facility.

LPAs observed a central entry point with a supply of hand sanitizer and a sign in policy that includes documented routine symptom screening for resident's, staff and visitors.

Mitigation plan has been submitted to Community Care Licensing. Infection control procedures described in the plan and observed by LPAs include: Daily symptoms screenings (for staff, persons in care and visitors), visitation policy, quarantine/isolation procedures, surveillance testing, infection control plan and identification of La Shay Ayers as the Infection Control Lead, emergency staffing, PPE use, infection control training and procedures, documentation, postings and communication. LPAs reviewed Mitigation Plan and procedures with the Administrator.

LPAs toured the facility inside and out. Required postings of signs to include hand washing, coughing etiquette and physical distancing were observed in the facility. Staff were all observed wearing face coverings. Facility has designated visitation areas. LPAs observed a 30day supply of PPE and resident medications. Sinks are well stocked and liquid soap for hand washing and paper towels for hand drying were observed.

Through LPA’s observations, documentation review and interview with Administrator, the required infection control practices are found to be in compliant. No deficiencies cited on today’s inspection.

Licensee to submit the following information to Fresno CCL within 11/10/21 calendar days:



1.) Current Facility Staff Work Schedule form LIC500
2.) Current Register of Facility Clients/Residents form LIC9020
3.) Copy/copies of current Administrator Certificate(s)
4.) Copy of current liability insurance coverage.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Les XiongTELEPHONE: (559) 410-1772
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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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