336407087-9-23-2024-18-AS-KBAG-D9DTCN-20240923143701

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336407087
Report Date: 09/23/2024
Date Signed: 09/23/2024 06:18:41 PM

Document Has Been Signed on 09/23/2024 06:18 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 CARE		FACILITY NUMBER:	336407087
ADMINISTRATOR:	TELECIA COOKE		FACILITY TYPE:	740
ADDRESS:	37225 JEROME LANE		TELEPHONE:	(951) 677-1349
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92562
CAPACITY:	8	CENSUS: 7	DATE:	09/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:59 PM
MET WITH:	Administrator, Telecia Cooke		TIME COMPLETED:	02:50 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 Analysts (LPAs) Kathleen Banrasavong and Armando Perez, along with CDSS’s Program Clinical Consultant, Dennis Bagayawa arrived unannounced to conduct an annual inspection. Upon arrival LPAs were greeted by facility staff and granted entry. LPAs began inspection with introduction and visit purpose. Upon arrival LPAs learned that seven (7) residents live at this facility. There was two (2) staff members present. The Administrator, Telecia Cooke was advised of the annual and came to conduct and completed the facility tour. Client Records/Incident Reports/Clients Rights Information: LPAs reviewed client records. Seven (7) records were reviewed. LPAs reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/ Staffing/ Administration: LPAs reviewed employee records. Two (2) records were reviewed. LPAs reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Telecia Cooke, Administrator’s certificate expiration date was 04/08/2022. The Administrator submitted her renewal to the Department of Social Services on 07/11/2023. Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a location for sharps in the kitchen.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: COPPER CANYON SENIOR CARE	FACILITY NUMBER: 336407087
	VISIT DATE: 09/23/2024

NARRATIVE

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Physical Plant and Safety of Environment/Operational Requirements: LPAs toured the facility inside and outside. LPAs observed the facility to be clean and in good repair. The facility is maintained at 76 degrees for the client’s comfort. Lighting is sufficient for safety. Water temperature measured 108.0 degrees F. Laundry is done in the garage. There is a locked location for storing laundry soap, cleaning supplies and chemicals in the closet in the garage. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. LPAs dialed the facility’s landline number, which rang and was operable. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There are one (1) secured fireplace at this facility. There are zero (0) pools at the facility. There are two (2) secured gates that has a self-latching lock located on the northwest and northeast side of the house. LPAs observed emergency supplies and one (1) first aid kit. The last emergency fire drill was conducted on 06/31/2024.

Infection Control: The LPAs observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPAs observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPAs reviewed the facility's infection control plan which met department requirements. LPAs reviewed staff records and found that staff had infection control training.

Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. LPAs reviewed medication logs and observed that they were dispensed accurately.

LPAs made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPAs observed nine (9) dual smoke detectors and two (2) carbon monoxide detectors throughout the facility. There were three (3) fire extinguishers on site, date charged was 05/30/2024.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: COPPER CANYON SENIOR CARE	FACILITY NUMBER: 336407087
	VISIT DATE: 09/23/2024

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 26 27 28 29 30 31 32	Pursuant to Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to Administrator, Telecia Cooke.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

LIC809 (FAS) - (06/04)

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