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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209183
Report Date: 11/25/2024
Date Signed: 11/25/2024 05:28:20 PM

Document Has Been Signed on 11/25/2024 05:28 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:COPPER RIVER RETIREMENT GROUP - LOYOLAFACILITY NUMBER:
107209183
ADMINISTRATOR/
DIRECTOR:
AYERS, LA SHAYFACILITY TYPE:
740
ADDRESS:419 W LOYOLA AVETELEPHONE:
(559) 936-9302
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY: 6CENSUS: 6DATE:
11/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:20 PM
MET WITH:Administrator - Shay AyersTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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On 11/25/2024, Licensing Program Analyst (LPA) M. Vega arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Staff 1 (S1), Administrator was contacted by phone and arrived a short moment later. LPA toured facility with Administrator (AD) Shay Ayers, AD certification number 6033549740.

The facility was observed to be at a comfortable temperature, of 70 degrees F. Facility is free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. LPA observed some residents in common area in the afternoon watching television, others in their rooms resting. Department phone number and infection prevention information signs were posted thought the facility.

Inspecting kitchen LPA observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. An emergency disaster supply was observed.

Fire extinguisher was observed with a service date of 07/22/2024. All 6 residents’ bedrooms were observed to be with comfortable temperature. Bathroom water temperature was tested and recorded reading of 118.5 degrees F.
Medications observed to be locked in a cabinet near the kitchen. LPA reviewed medication records are maintained at the time of inspection. Cleaning supplies were observed to be in a locked and inaccessible to residents.

Continuation on LIC 809C

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Martin Vega
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: COPPER RIVER RETIREMENT GROUP - LOYOLA
FACILITY NUMBER: 107209183
VISIT DATE: 11/25/2024
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An outdoor seating area was observed for residents in care, seating area in good repair. Fountain outside with no standing water observed.

LPA reviewed Staff and Resident files. Resident files observed to have updated information.

No deficiencies were observed and cited. Exit interview conducted.
Report was signed and copy of this report was provided for facility records.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Martin Vega
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC809 (FAS) - (06/04)
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