Copper River Retirement Group

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Administrator Shay Ayers, Continual Administrator's Certification expires 12/09/2026. There are currently 5 residents who reside at this home and there is 1 resident on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable. Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 109.6 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA reviewed 2 facility staff files, 4 facility resident files, Plan of Operation, Emergency Disaster Plan, and Infection Control Plan. There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22. LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing. Exit interview conducted with Administrator, Shay Ayers, and copy of report left at facilitythe state’s words, verbatim · CDSS document, Dec 15, 2025

Type of visit: Required - 1 Year

On 12/23/2024 Licensing Program Analyst (LPA) K.Kaur arrived at facility unannounced to complete an Annual inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Direct Care Staff, Clinton Arciete. Licensee/ Administrator Shay Ayers was contacted and arrived a short time later. The facility has 5 residents, of which all were present during the inspection. LPA toured the facility with the Administrator. Tour started in the kitchen. Knives were locked in the kitchen cabinet. LPA observed a 7-day supply of non-perishable foods and 2-day supply of perishable foods. Cleaning supplies observed locked in the cabinet under the kitchen sink. The dining room is equipped with a table and chairs, the living room is equipped with adequate sofas and recliners for seating. Medications, first aid kit observed locked in the hallway closet. Residents' bedrooms were observed to be adequately furnished with beds, dresser, and adequate lighting. Mattresses and linen were in good condition. At 12:33 PM LPA observed one of the resident’s window screen frame was bent. The laundry area toured and observed with locks on all cabinets. Extra linen and towels are available in the hallway closet. LPA observed grab bars installed by toilet and non-skid mats in place. Smoke alarm detectors and Carbon monoxide detectors installed and operational. Adequate outside space for rest and recreational. Sufficient seating observed under a covered patio. The fire extinguisher in kitchen was serviced July 22, 2024. Backyard gate is self-closing and self-latching. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report and ID Documentation. Medication reviewed. Staff files were reviewed for good health. At 1:43 PM LPA observed one of the resident’s physician’s report was not signed by a physician. Staff files had health screenings/ TB Clearance. It was verified that current staff on duty are CPR certified. Last Fire Drill conducted in September 2024.. Continued to 809C... Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6. LPA is requesting the following documents be submitted to the Fresno CCL office by 12/30/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020. An exit interview was conducted with Licensee. Report signed on-site; a copy of this report, 809D with appeal rights was provided via email due to technical difficulties.the state’s words, verbatim · CDSS document, Dec 23, 2024

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 3/20/2024 Licensing Program Analyst B. Miranda arrived at the facility unannounced to conduct a case management. LPA introduced herself and requested to speak with the Administrator. Shay Ayers was contacted and arrived shortly after. LPA explained this was a follow up visit from the annual inspection on 1/22/2024 regarding the door flip locks on various exits throughout the facility. LPA previously explained the flip locks are not allowed unless it was previously cleared by the Fire Dept. As of today 3/20/24, no verification was provided to the Dept verifying the flip locks being cleared to use. LPA observed all flip locks to have been removed. Due to locks originally being on the exits doors during the annual inspection citation was issued for deficiency. Citation was issued under Title 22, Division 6, Chapter 8 on LIC809D form. Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Shay Ayersthe state’s words, verbatim · CDSS document, Mar 20, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(1)(2) · Plan of correction due date: Mar 21, 2024

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (1) Non ambulatory persons. (2) Bedridden persons This requirement is not met as evidenced by: Based on observation, interview, and record review on 1.22.24 the licensee failed to maintain a fire clearance. LPA observed door flip locks on all exit routes which included front door, back door, garage door leading to outside, and one on the outside of R1’s room. This creates a obstruction when trying to exit during an emergency. This poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: On 3/20/24 LPA observed all flip locks to have been removed and POC will be cleared.

Allegation investigated: Financial Abuse

On 01/22/2024 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to deliver the finding for the allegations listed above. LPA introduced herself and explained the reason for the visit. LPA met with Licensee Shay Ayers. LPA conducted a walk around tour of the facility inside and out and verify there was no immediate danger. 1. The Department investigated the allegation: Financial Abuse. Interviews were conducted between resident and staff member. LPA also reviewed records of charges that cleared and declined, admissions agreement, and R1's physician report. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview was conducted and a copy of this report LIC9099 was provided to Licensee Shay Ayers. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 22, 2024 · control 24-AS-20230830134334

Type of visit: Required - 1 Year

On 1/22/24 Licensing Program Analyst (LPA) B. Miranda conducted an unannounced Required - 1 Year Annual. LPA explained the reason for the visit and Licensee Shay Ayers was contacted and arrived shortly after. LPA toured the facility inside and out to include entry, kitchen, dining, living room, bedrooms, bathrooms, and exterior. All fire exit routes have a clear pathway but have an additional door flip lock which creates an obstruction. Facility will provide verification of clearance by end of business day 1/29/24 Medications are stored in a locked closest in the facility. Toxins, cleaning supplies, knives and sharp objects are secured and inaccessible to residents. Facility is at maximum capacity with 6 residents each having their individuals rooms. LPA observed the facility to be clean, free from clutter, and odor free. First aid kit is complete. LPA observed supply of Personal Protective Equipment (PPE). Fire extinguishers have been services as of 07/28/23 and are in good standing. Smoke alarms and carbon monoxide reader was tested and in working condition. Water temperature was checked in the bathroom and read at 105.3 degree Fahrenheit. LPA reviewed a sample of employee files which are current and up to date with training. LPA observed a sample of resident's charts which are current. Liability insurance is current and up to date. Citation was not issued at this time, if facility is not able to provide verification citation will be issued at a later date. Exit interview was conducted and a copy of this report LIC809 were provided to Licensee Shay Ayers.the state’s words, verbatim · CDSS document, Jan 22, 2024