Copper River Retirement Group - Loyola

Type of visit: Required - 1 Year

On 11/02/2023, Licensing Program Analyst (LPA) V. Gorban 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. LPA toured facility with staff Eloy. Administrator (AD) Shay Ayers was notified of Licensing visit over the phone and was able to attend the visit. AD certification number 6033549740. The facility was observed to be at a comfortable temperature, of 78 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 after breakfast 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 07/28/2023. All 6 residents’ bedrooms were observed to be with comfortable temperature. Bathroom water temperature was tested and recorded reading of 108 degrees F. Medications observed to be locked in a cabinet in the kitchen. LPA reviewed medication records appears to be administered properly. Cleaning supplies were observed to be in a locked cabinet in the laundry room. An outdoor seating area was observed operational for residents in care. 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.the state’s words, verbatim · CDSS document, Nov 2, 2023

Type of visit: Required - 1 Year

On 11/28/2022, Licensing Program Analyst (LPA) V. Gorban arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Administrator, Lashay Dustin, certificate expiration on 12/09/2022. Visitor log-in/temperature check station was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Hand washing and other various Covid-19 related signs were observed in the common areas. Facility staff was observed with mask covering. The facility was observed to be at a comfortable temperature, free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. PPE and chemicals were observed locked in a laundry room. A 2-day supply of perishable and 7-day supply of non-perishable food was observed to be properly stored and labelled. Fire extinguisher was observed with a service date of 07/13/2022. All 7 bedrooms were observed to be adequately furnished with bed, 6 rooms are residents private rooms with dresser, and adequate lighting. Sample of residents file was reviewed for emergency contact. No deficiencies were observed. Administrator was provided the source to Title 22 and PINs update information. LPAs are requesting the following documents to be provided to the Fresno CCL office by 12/27/2022: Current copy Of: LIC 308 Designation of Facility Responsibility · -as applicable: LIC 309 Administrative Organization · -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources · -as applicable: LIC 402 Surety Bond · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly · LIC 9020 Register of Facility Clients/Residents · Copy of current Liability Insurance · Copy of current Administrator Certificate · Alternate contact information including name, telephone number, & email address. An exit interview was conducted with Administrator. Report signed on-site by Administrator and printed copy provided.the state’s words, verbatim · CDSS document, Nov 28, 2022

Allegation investigated: Facility did not issue refund to resident's authorized representative.

Licensing Program Analyst (LPA) L. Xiong conducted the subsequent complaint investigation visit to the facility. I met with La Shay Ayers, Administrator and informed her the purpose of visit. During the course of this complaint investigation LPA interviewed staff and obtained and/or reviewed facility records. It was determined based on the interviews and records review that the above allegation is SUBSTANTIATED. Facility did not issue refund to resident's authorized representative. It was discovered that there were no Admission Agreement signed between the authorized representative and the facility. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.”) Substantiatedthe state’s words, verbatim · CDSS document, Apr 6, 2022 · control 24-AS-20220314132847

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(a) · Plan of correction due date: Apr 13, 2022

87507 Admission Agreements (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. It was discovered during the investigation that there were no Admission Agreement signed between the authorized representative and the facility. This requirement was not met as evidenced by: Based on interviews, facility failed to issue refund to resident's authorized representative. This posed a potential risk or (an immediate risk) to the health, safety and/or personal rights of clients in care.the state’s words, verbatim · CDSS document, Apr 6, 2022

Plan of correction: Per Administrator, will contact the referral agent and issue the refund to the authorized representative through them by the POC date.

Type of visit: Prelicensing

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.the state’s words, verbatim · CDSS document, Nov 29, 2021

Type of visit: Office

COMP II by CAB successfully completed. Facility Type: RCFE Application Type: Initial Capacity: 6 (5 non-ambulatory and 1 bedridden) Census (if any clients in care): 0 COMP II Participants: La Shay Ayers, Administrator Interview Method: Telephone interview On November 10, 2021 at 9:00 AM, Administrator participated in COMP II via telephone with Analyst, Celia Phomphachanh from CAB. Identification of the Licensee was verified by providing California Driver License number verbally. During COMP II, Applicant confirmed the understanding of Title 22 and Health and Safety Codes. Component II was successfully completed. Administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB Analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility Operation: License type, client/resident populations, and program 2. Staff Qualifications and responsibilities 3. Applicant and Administrator Qualifications 4. Program Policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical Plant and Food Service 7. Application Document Review and Technical Assistance: Criminal Record Clearance, Health Screening, Fire Clearance, First Aid/CPR Certificate, Administrator Certificate, Financial Verification, Pre-licensing Inspection, Compliance History and Control of property. Interviewed concluded with Administrator. LIC 809 will be sent via email PDF to Administrator.the state’s words, verbatim · CDSS document, Nov 10, 2021