107209092-10-21-2022-24-AS-VGON-CKEV94-20221021161342

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107209092
Report Date: 10/21/2022
Date Signed: 10/21/2022 04:16:55 PM

Document Has Been Signed on 10/21/2022 04:16 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

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: 6	DATE:	10/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, La Shay Ayers		TIME COMPLETED:	11:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/21/2022, Licensing Program Analysts (LPAs) V. Gorban and Sarah Hurt arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA introduced selves, stated the purpose of the visit, and was granted entry to the facility by Administrator, LA Shay Ayers. Visitor log-in/temperature check station was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Hand washing and other various Covid-19 related signs were observed in the common areas. Facility staff was observed with mask covering. The facility was observed to be at a comfortable temperature, free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. PPE observed by facility entrance. A 2-day supply of perishable and 7-day supply of non-perishable food was observed to be properly stored. Fire extinguisher was observed with a purchase date of: 07/13/2022. Resident's Bedrooms were observed to be adequately furnished with bed, dresser, and adequate lighting. Sample of residents file was reviewed for emergency contact. LPA's confirmed facility staff present is background cleared. LPA's confirmed facility staff has COVID 19 vaccine cards or exemptions on file. LPA's observed a hallway closet with cleaning supplies, and bleach unlocked and accessible to residents. Continued to LIC809 C

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: COPPER RIVER RETIREMENT GROUP - BUCHANAN	FACILITY NUMBER: 107209092
	VISIT DATE: 10/21/2022

NARRATIVE

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LPAs are requesting the following documents to be provided to the Fresno CCL office by 10/31/2022: Current copy
of Administrator Certificate, Designation of Facility Responsibility (LIC308), Emergency and Disaster Plan (LIC610D) , Personnel Report (LIC500).
LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Liability Insurance
· Copy of current Administrator Certificate
· Alternate contact information including name, telephone number, & email address.

The following deficiency is being cited today Per Title 22 Regulations.

An exit interview was conducted with Administrator. Report signed on-site by Administrator and printed copy provided.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/21/2022 04:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: COPPER RIVER RETIREMENT GROUP - BUCHANAN	FACILITY NUMBER: 107209092
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/04/2022
	Plan of Correction
1 2 3 4	Licensee will conduct staff training on hazardous toxins, chemicals, and submit proof to LPA by 11/04/2022 POC date. Licensee will move all chemicals into one area and ensure it is locked at all times, and provide proof to LPA by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC809 (FAS) - (06/04)

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