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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209183
Report Date: 11/29/2021
Date Signed: 11/29/2021 02:22:03 PM

Document Has Been Signed on 11/29/2021 02:22 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
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: 0DATE:
11/29/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:La Shay AyersTIME COMPLETED:
03:09 PM
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On or about today's date LPA, Les Xiong was at the above facility for an announced Pre-licensing visit. LPA met with La Shay Ayers, Administrator and Assist. Administrator, Clinton Arciete.

Contact Phone number is (559) 396-9302 email: shay.copperriver@gmail.com


LPA toured the above facility. Common rooms have adequate furnishings. All of the resident bedrooms have adequate lighting. Hot water temperature is measured at 106 degrees on the east wing and 120 degrees at the west wing. LPA observed a supply of extra bed linens and personal hygiene and grooming products. Kitchen and pantry observed to have 2 day perishable and 7 day non-perishable food on hand and ready for food storage and preparation. Medications will be kept in a locked storage/medication closet in the west wing hallway. First aid kit contains all the required items. A fire extinguisher is present and up to date. Smoke detectors/carbon monoxide were present and functional.

No hazards were observed.

Component 3 orientation was conducted during this visit. All required postings are posted.

I have found that applicant has met all pre-licensing requirements. LPA will submit the application for further processing.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2021
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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