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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209092
Report Date: 10/31/2024
Date Signed: 10/31/2024 03:40:44 PM

Document Has Been Signed on 10/31/2024 03:40 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 - BUCHANANFACILITY NUMBER:
107209092
ADMINISTRATOR/
DIRECTOR:
AYERS, LA SHAYFACILITY TYPE:
740
ADDRESS:232 OMAHA AVETELEPHONE:
(559) 396-9302
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY: 6CENSUS: 5DATE:
10/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:La Shay Ayers - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 10/31/2024, Licensing Program Analyst (LPA) M. Vega arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by facility Staff 1 (S1). (AD) Shay Ayers was notified of Licensing visit over the phone and was able to attend the visit. LPA toured facility with staff La Shay Ayers - Administrator, AD certification number 6033549740 and expiration date 12/09/2024

Facility has one entrance/exit point. LPA toured facility with Administrator inside and out. Facility pool serviced weekly. LPA observed pool in the back yard, fenced and the gate to the pool was locked.
The facility was observed to be at a comfortable temperature, of 78 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 residents in their rooms resting, one resident was in the living room area. Department phone number and infection prevention information signs were posted thought the facility.

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 7/22/2024. All 6 residents’ bedrooms were observed to be with comfortable temperature.
Medications observed to be locked in a cabinet in the kitchen/hallway area. LPA reviewed medication records and there were no deficiencies at the time of inspection. Cleaning supplies were observed to be in a locked cabinet under the kitchen sink and in the laundry room. An outdoor seating area was observed for residents in care.

Continuation LIC 809C
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Martin Vega
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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 - BUCHANAN
FACILITY NUMBER: 107209092
VISIT DATE: 10/31/2024
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LPA reviewed Staff and Resident files. Resident files observed to have updated information.
No deficiencies were observed nor cited. Exit interview conducted.
Report was signed and copy of this report was provided for facility records.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Martin Vega
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC809 (FAS) - (06/04)
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