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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336407087
Report Date: 03/21/2024
Date Signed: 03/21/2024 03:09:25 PM


Document Has Been Signed on 03/21/2024 03:09 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:COPPER CANYON SENIOR CAREFACILITY NUMBER:
336407087
ADMINISTRATOR:TELECIA COOKEFACILITY TYPE:
740
ADDRESS:37225 JEROME LANETELEPHONE:
(951) 677-1349
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY:8CENSUS: 8DATE:
03/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Tiffany Cooke, AdministratorTIME COMPLETED:
03:10 PM
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
Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility. The LPA met with staff, Tiffany Cooke, and spoke with Administrator, Telecia Cooke, over the phone. During the visit the LPA observed the below violation.

The LPA observed a staff member, Staff One (S1) to not be listed on the facility personnel roster. A record review of the Department's Criminal Background Check database revealed no profile for S1 was found. A review of the staff member's file revealed S1 was fingerprinted for the California Department of Public Health not the California Department of Social Services. This poses an immediate threat to the health, safety and personal rights of the residents in care. Therefore, due to S1 not having an appropriate fingerprint clearance, a citation and civil penalty will be issued.

An exit interview was conducted with staff, Tiffany Cooke, due to the Administrator not being available at the time. The report was reviewed and a copy was provided, along with the LIC 811 and instructions on appeal rights.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/21/2024 03:09 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: COPPER CANYON SENIOR CARE
FACILITY NUMBER: 336407087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2024
Section Cited
CCR
87355(e)(1)

1
2
3
4
5
6
7
CRIMINAL RECORD CLEARANCE: (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a...facility: (1) Obtain a California clearance or a criminal record exemption as required...This requirement was not met, as evidenced by: Based on
1
2
3
4
5
6
7
The staff member left the facility prior to the conclusion of the visit.
8
9
10
11
12
13
14
observation & record review, the Licensee did not ensure all individuals subject to a criminal record review obtained a California clearance or a criminal record exemption. A record review of the Department's California Criminal Background Check database revealed no profile for S1 to be found.
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: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2