<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209183
Report Date: 04/06/2022
Date Signed: 04/06/2022 04:28:46 PM

Substantiated


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
03/14/2022 and conducted by Evaluator Les Xiong
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220314132847
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: 4DATE:
04/06/2022
UNANNOUNCEDTIME BEGAN:
03:33 PM
MET WITH:La Shay AyersTIME COMPLETED:
04:49 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not issue refund to resident's authorized representative.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 did not issue refund to resident's authorized representative. It was discovered that there were no Admission Agreement signed between the authorized representative and the facility. 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 PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Les XiongTELEPHONE: (559) 410-1772
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 24-AS-20220314132847
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 - LOYOLA
FACILITY NUMBER: 107209183
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/13/2022
Section Cited
CCR
87507(a)
1
2
3
4
5
6
7
87507 Admission Agreements
(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. It was discovered during the investigation that there were no Admission Agreement signed between the authorized representative and the facility.
1
2
3
4
5
6
7
Per Administrator, will contact the referral agent and issue the refund to the authorized representative through them by the POC date.
8
9
10
11
12
13
14
 This requirement was not met as evidenced by: Based on interviews, facility failed to issue refund to resident's authorized representative. This posed a potential risk or (an immediate risk) to the health, safety and/or personal rights of clients in care.
8
9
10
11
12
13
14
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 PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Les XiongTELEPHONE: (559) 410-1772
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2