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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209183
Report Date: 10/03/2024
Date Signed: 10/03/2024 11:44:40 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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
09/30/2024 and conducted by Evaluator Martin Vega
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240930141721
FACILITY NAME:COPPER RIVER RETIREMENT GROUP - LOYOLAFACILITY NUMBER:
107209183
ADMINISTRATOR:AYERS, LA SHAYFACILITY TYPE:
740
ADDRESS:419 W LOYOLA AVETELEPHONE:
(559) 936-9302
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY:6CENSUS: 5DATE:
10/03/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator - La Shay AyersTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not provide a supervision for resident, resulting in injury.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/03/2024 LPA M Vega conducted an initial 10-day investigation to open the complaint. Staff 1 answered the door and contacted administrator La Shay Ayers. LPA met with Administrator a short time after and stated the purpose of the visit.

1. The Department investigated the allegation: Facility staff did not provide a supervision for resident, resulting in injury. LPA conducted facility tour and reviewed records for R1 and R2. Per review LIC 624 was sent by facility, reviewed form and fax confirmation page.

The Department has investigated the above allegations and have found them to be unsubstantiated. Exit interview conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Martin Vega
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
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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