Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206814
Report Date: 04/14/2017
Date Signed 04/14/2017 02:26:20 PM

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 GROUP/SHEAFACILITY NUMBER:
107206814
ADMINISTRATOR:DEMETRIA CAMMON-MYERSFACILITY TYPE:
740
ADDRESS:2617 E. SHEA DRIVETELEPHONE:
(559) 325-7383
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:6CENSUS: 0DATE:
04/14/2017
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee Representative, Alice Hayes
Director of Operations, La Shay Dustin
Landlord, Stephanie Costa, Daughter of Alice Hayes
Attorney-at-Law, Joel Goldman
TIME COMPLETED:
03:00 PM
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A Non-Compliance Conference (NCC) was conducted today at Fresno Adult & Senior Care Regional Office. The purpose of this Non-Compliance Conference is to discuss concerns regarding the involvement of a previously excluded staff Stephanie Costa in the operation of the Copper River Retirement Group and/or Clear View Retirement Group.

Present at the meeting were:



Lead Licensing Program Manager Irma Valles
Licensing Program Manager Shelley Evans
Licensing Program Analyst Irosimhe Orbih-Chukwu
Licensing Program Analyst Sergiy Pidgirny

Licensee Representative, Alice Hayes
Director of Operations, La Shay Dustin
Landlord, Stephanie Costa, Daughter of Alice Hayes
Attorney-at-Law, Joel Goldman

Licensee Representative, Alice Hayes and Director of Operations, La Shay Dustin
signed declarations that they know that Ms. Stephanie Costa may not have unsupervised contact with clients and may not be involved in any capacity with the operation of any of the Copper River Retirement Group and/or Clear View Retirement Group facilities including but not limited to performing the functions and the job duties of the facility Administrator and/or Director of Operations.
SUPERVISOR'S NAME: Shelley EvansTELEPHONE: (559) 243-8739
LICENSING EVALUATOR NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2017
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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