CALIFORNIADEPARTOIENTOFSOCIALSERVICES COMMUNITTCARE UCENSING DIVISION CCLDRegionalOffice,1314E SHAWAVE FRESNO. CA83710 STATE OF CAUFORNIA - HEALTH AND HUMAN SERVICES AGENCY NONCOMPUANCECONFERENCESUMMARY NAMEANDADDRESSOFFACILnV: CLEAR VIEW RETIREMENT GROUP/JON 2846 E. JON DRIVE FRESNO, CA 93720 FACILITYLICENSENUMBER: EFFECTIVEDATEOF UCENSE: 107206812 LICENSEE LICENSECAPACITr: 12/05/2014 STATUS: 6 FACILnYWPE: 3 740 ME( : CLEARVIEW RETIREMENT GROUP LLC NAME AND FACILITY NUMBER OF OTHER COMMUNIT/ CARE, CHILD DAY CARE, RESIDENTIAL CARE FACILITIESFORTHE ELDERLY,OR HEALTHFACILITIESLICENSEDTO OROWNEDBYAPPLICANT(S) WITHINTHE LAST FIVEYEARS. FACILITf NUMBER FACILITCNAME A. COPPER RIVER RETIREMENT GROUP 107206811 107206815 107206814 107206816 107206812 B. COPPERRIVERRETIREMENTGROUP/EVERGLADE C. COPPERRIVERRETIREMENTGROUP/SHEA D. CLEARVIEWRETIREMENTGROUP E. CLEAR VIEW RETIREMENT GROUP/JON F. CLEARVIEWRETIREMENTGROUP/SKYVIEW DATE OF CONFERENCE; 04/14/2017 107206813 LICENSINGPROGRAMANALYST: Irosimhe Orbih-Chukwu LICENSINGPROGRAMMANAGER: Present at meeting: NAME TITLE Irma Valles Lead Licensing Program Manager Shelley Evans Licensing Program Manager Licensing Program Analyst Licensing Program Analyst Licensee Representative Directorof Operations Irosimhe Orbih-Chukwu Sergiy Pidgimy Alice Hayes La Shay Dustin Stephanie Costa Joel Goldman Licaiii - (iaaa) - (PUBLIC) Landlord Attomey-at-Law Page: 1 of 4 STATEOFCALIFORNIA- HEALTHANDHUMANSERVICESAGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNmrCARELICENSINGDIVISION CCU) Regtonal Office, 1314 E SHAW AVE FRESNO. CA93710 NONCOMPLIANCE CONFERENCE SUMMARY PAGES NAME AND ADDRESS OF FACILnY: CLEAR VIEW RETIREMENT GROUP/JON 2846 E. JON DRIVE FRESNO, CA 93720 FACILITCLICENSENUMBER: EFFECTIVEDATEOFLICENSE; 107206812 12/05/2014 L EN E PACffY: STATUS: FACILm'T»TE: 740 6 LICEN EENAME(S): CLEARVIEWRETIREMENTGROUPLLC Licenseeagreedto dothefollowingin orderto bringthefacilityintocomplianceno laterthanthe followingdates: 1 Licensee Representative, Alice Hayes and Director of Operations, La ShayDustin 2 agreed to sign declarations stating that they knowand understand that Stephanie Costa may not have 3 unsupervised contact with clients and may not be involved in any capacity with the operation ofanyof the Copper River Retirement Group and Clear View Retirement Groupfacilities including but not g limited to performing thefunctions andthejob duties ofthefacilityAdministrator and/or Director of 7 Operations. 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LICENSEESIGNATURE (/ DATE: v)0 MANAGERSIGNATURE: 04/14/2017 DATE: 04/14/2017 L^ LC9111(FAS)- (12f99)- (PUBLIC) Page:2 nf4 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY NONCOMPLIANCE CONFERENCE SUMMARY PAGE 4 CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITYCARELICENSINGDIVISION COLD RegiDiBl Office, 131* E SHAW AVE TOESNO.CA93710 NAMEANDADDRESSOF ACILmr: CLEARVIEWRETIREMENTGROUP/JON 2846 E. JON DRIVE FRESNO,CA 93720 FACILfn'LICENSEN MBER: ELECTIVEDATEOFLICENSE: 107206812 LICENSECAPACITV: STATUS: FACILFYTfPE: 12/05/2014 740 LICENSEE NAME(S): CLEARVIEWRETIREMENTGROUPLLC Licensee has been advised that failure to complete the above agreed upon actions by the dates will result in this Department taking the following action(s): 1 Ms.AliceHayesand Ms. LaShayDustinwereinformedthatthe Departmentcould immediately 2 take administrative actions against Copper River Retirement Group and Clear View Retirement 3 4 5 6 Group facilities with the evidence obtained. Licensee Representative, Alice Hayes and Director of Operations. LaShay Dustin were also informed that all Copper River Retirement Group and/or Clear View Retirement Group facilities will be under increased monitoring by the Department. They were also informed that any and all further violations of the Decision and Order issued by the Department will result in imrtiediateadministrative action to revole the licenses of Copper River Retirement Group LLC and Clear View Retirement Group LLC 7 8 9 10 11 12 13 14 15 The licensee understands and acknowledges that the Department, at its discretion, will make increased unannouncedcase managementvisits to monitor the licensee's compliance. 16 17 The Department is not deprived of its authority to take appropriate formal legal action under the Health and SafetyCode when such action is deemed necessarybythe Director. 18 19 20 21 22 23 In the event that formal legal action is taken, nothing in this plan precludes the Department from including Non-Complianceissues referred to in this Non-Compliancemeeting. 24 25 26 27 28 29 30 D A detailed letter regarding this conference will be mailed to the licensee within 5 calendardays. LICENSEE SIGNATURE DATE: 04/14/2017 <7M <7\c MANAGERSIGNATURE: / n - UC9111 (FAS). (12B9) . (PUBLIC) DATE: r>^^CL 04/14/2017 Page: 3 of 4 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY NONCOMPLIANCE CONFERENCE SUMMARY PAGE 2 CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITYCARELICENSINGOIVISION CCLD RBglonal Office, 1314 E SHAWAVE FRESNO. CA 93710 NAMEANDADDRESSOF FACILrTf: CLEAR VIEW RETIREMENT GROUP/JON 2846 E. JON DRIVE FRESNO, CA 93720 FACILITYLICENSENUMBER: EFFECTIVEDATE FU EN E: 107206812 12/05/2014 LICENSECAPACITT: STATUS: 6 FACILHY T/PE: 3 740 LICENSEENAME(S): CLEARVIEWRETIREMENTGROUPLLC This Noncompliance Conference was called to discuss the following issues or deficiencies: 1 The purpose of this Non Compliance Conference is to discuss concerns regarding the involvement of 2 a previouslyexcludedstaff, StephanieCosta, in the operationoffacilities licensedto CopperRiver 3 Retirement Group LLC and Clear ViewRetirement Group LLC. J Thedepartmentprovided evidenceofStephanieCostadirectinvolvement whichincludedcopiesofthe 7 text messages and information obtainedfrom currentandformeremployees. 8 9 10 As a result of this infomiationthe department has determined that StephanieCosta has violated the 11 exclusiondecisionandorder issued bythe departmenton May3rd 2016andwhichbecameeffective 12 inJuly6 2016.ThisviolationoccurredbecauseStephanieCostahasbeendirectlyinvolvedinthe ]3 hiring and termination of staffworking at the Copper River Retirement Group and Clear View ^g Retirement Group facilities. . 16 17 During this meeting the Decision and Order was reviewed. It states that: 18 19 As a result of the Decision and Order Ste hanie Costa is rohibited from em lo ment in resence in 20 and contact with clients of an facili licensed b the De artment or certified b a licensed foster 21 famil a enc and from holdin the osition of member of the board of directors executive director or 22 officerofthelicenseeofan facili licensedb theDe artment fortheremainderofMs. Costa'slife. 24 25 26 27 28 29 30 31 32 LICENSEESIGNATURE DATE: 1^ MANAGERSIGNATURE: 04/14/2017 DATE: 04/14/2017 LIC9111 (FAS>-(12re»>-(PUBLIC) Page:4 of 4 STATEOFCALIFORNIA- HEALTHANDHUMANSERVICESAGENCY CALIFORNIADEPARrMENTOF SOCIALSERVICES FACILITYEVALUATIONREPORT CCLORegionalOffice,1314E SHAWAVE COMMUNIF/CARELICENSINGDIVISION FRESNO; CA 9371() FACILITY NAME: CLEAR VIEWRETIREMENT GROUP/JON FACILITY NUMBER: 107206812 FACILITYTYPE: TELEPHONE: ZIP.CODE: FRESNO STATE: CA DATE: 6 CENSUS: 0 Office UNANNOUNCED TIME BEGAN: Licensee Representative, Alice Hayes Director of Operations, La Shay Dustin TIME COMPLETED: Landlord, Stephanie Costa, Daughter of Alice Hayes Attomey-at-Law,Joel Goldman 740 (559) 322-7368 93720 04/14/2017 01:OOPM ADMINISTRATOR:PAMELASTANCOFF ADDRESS: 2846 E. JON DRIVE Cirr: CAPACITY: TVPEOF VISIT: MET WITH: 03:00 PM NARRATIVE 1 2 3 4 5 6 7 A Non-CompIianceConference (NCC) wasconducted today at FresnoAdult& SeniorCare Regional Office. The purposeofthis Non-ComplianceConference is to discussconcerns regarding the involvement of a previously excluded staff Stephanie Costa into the operation of the Copper River Retirement Group and/or Clear View Retirement Group. Present at the meetin were: 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Lead Licensing Program Manager Irma Valtes Licensing Program Manager Shelley Evans Licensing Program Analyst Irosimhe Orbih-Chukwu LicensingProgramAnalyst Sergiy PJdgirny Licensee Representative, Alice Hayes Director of Operations, La Shay Dustin Landlord, Stephanie Costa, Daughter of Alice Hayes Attorney-at-Law,Joel Goldman LicenseeRepresentative, Alice Hayesand DirectorofOperations, La Shay Dustin signeddeclarationsthat they knowthat StephanieCostamay not haveunsupervised contactwith 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 functionsandthejob duties ofthefacilityAdministratorand/or Directorof Operations. SUPER SOR'S N ME: Shelley Evans TELEPH NE:(559) 243-8739 LICENSING EVALUATOR NAME: trosimhe Oriiih-Chukwu TELEPHONE: (559) 243-8080 LICENSINGEVALUATORSIGNATURE: DATE: 04/14/2017 I acknowledgereceipt ofthisform and understand my licensing appeal rights as explainedand received. FACILITYREPRESENTATIVESIGNATURE: ^ *^\ DATE:04/14/2017 This report must be available at Child Care and Group Home facilities for public review for 3 years.