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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206811
Report Date: 01/14/2022
Date Signed: 01/14/2022 07:05:36 PM

Document Has Been Signed on 01/14/2022 07:05 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 GROUPFACILITY NUMBER:
107206811
ADMINISTRATOR:APOLINARIO P PEREZFACILITY TYPE:
740
ADDRESS:1115 E. PINEHURSTTELEPHONE:
5594330488
CITY:FRESNOSTATE: CAZIP CODE:
93730
CAPACITY: 6CENSUS: 6DATE:
01/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Shay Dustin, LicenseeTIME COMPLETED:
05:10 PM
NARRATIVE
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On 1/14/22 at 2:35 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management - deficiencies inspection. LPA explained reason for inspection and was granted entry. Licensee (LIC) Shay Dustin arrived a short time later.

S1 and S2 are not fingerprint cleared. Both S1 and S2 have been working in the facility since 9/6/21.

During the complaint investigation #24-AS-20211026095919, LPA found that Licensee did not immediately provide a copy of the admission agreement to R1 and R1's responsible party upon signing the admission agreement. Licensee admitted she did not provide a copy to R1 or R1's responsible party immediately upon signing the admission agreement and stated she provided the copy of the admission agreement the following day to staff to give to R1 and R1's responsible party.

Deficiencies are being cited based on LPA observations, interviews conducted, and records review in accordance with the California Code of Regulations, Title 22, see LIC9909D.

Exit interview conducted. Due to COVID-19 precautionary measures, a copy of this report and appeal rights were emailed to email on record with "Read receipt" to confirm receipt of this report. LPA confirmed email on record is correct with Licensee.

SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2022
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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Document Has Been Signed on 01/14/2022 07:05 PM - It Cannot Be Edited


Created By: Malia Thao On 01/14/2022 at 04:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: COPPER RIVER RETIREMENT GROUP
FACILITY NUMBER: 107206811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/14/2022
Section Cited
CCR
87355(d)

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87355 Criminal Record Clearance (d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.

This requirement is not met as evidenced by:
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Licensee immediately removed S1 and S2 from the facility during inspection. POC cleared.
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S1 and S2 are not fingerprint cleared. Both S1 and S2 have been working in the facility since 9/6/21. This poses an immediate health, safety, and personal rights risk to residents in care.
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Type B
01/21/2022
Section Cited
CCR87507(e)

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87507 Admission agreements (e) The licensee shall provide a copy of the signed and dated current admission agreement...immediately upon signing the admission agreement or modification...

This requirement is not met as evidenced by:
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Licensee will submit proof of plan of how a copy of the admission agreement will be provided immediately to residents and resident's responsible party upon signing, to CCL by POC due date.
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During the complaint investigation #24-AS-20211026095919, LPA found that Licensee did not immediately provide a copy of the admission agreement to R1 and R1's responsible party upon signing the admission agreement. Licensee admitted she did not provide a copy to R1 or R1's responsible party immediately upon signing the admission agreement and stated she provided the copy of the admission agreement the following day to staff to give to R1 and R1's responsible party. This poses a potential personal rights risk to residents in care.
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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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2022


LIC809 (FAS) - (06/04)
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