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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107200486
Report Date: 12/14/2021
Date Signed: 12/14/2021 10:34:08 AM

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:SIERRA PALACE FOR ELDERLYFACILITY NUMBER:
107200486
ADMINISTRATOR:PERERA-MORELAND, ELIZABETHFACILITY TYPE:
740
ADDRESS:607 E. SIERRA AVENUETELEPHONE:
(559) 435-6345
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY:6CENSUS: 5DATE:
12/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Elizabeth Perera, Administrator TIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Lady Cabrera conducted an unannounced case management visit to the facility. LPA met with Administrator Elizabeth Perera and stated the purpose of the visit.

The purpose of the case management visit is to respond an incident report that was submitted to CCL Office incident occurred on 10/19/2021 regarding Resident (R1) and R2. R1 was in the living room watching television and R2 went up to him and pinched his hand. R1 then grabbed R2's wheelchair and pushed him away and R2's wheelchair flipped over and R2 fell. Staff immediately intervene and separated clients. Staff called non-emergency ambulance to evaluate R2.

No follow-up required.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
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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