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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107200486
Report Date: 12/14/2021
Date Signed: 12/14/2021 10:24:11 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/24/2021 and conducted by Evaluator Lady Cabrera
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210924153141
FACILITY NAME:SIERRA PALACE FOR ELDERLYFACILITY NUMBER:
107200486
ADMINISTRATOR:PERERA, NEILFACILITY TYPE:
740
ADDRESS:607 E. SIERRA AVENUETELEPHONE:
(559) 435-6345
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY:6CENSUS: 5DATE:
12/14/2021
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Elizabeth Perera, AdministratorTIME COMPLETED:
10:23 AM
ALLEGATION(S):
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9
Facility is not following COVID-19 guidelines.
Facility does not have proper PPE for staff.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lady Cabrera conducted the subsequent complaint investigation visit to the facility.

During the course of this complaint investigation LPA conducted interviews and reviewed records. It was determined based on the interviews and records review that the above allegations are SUBSTANTIATED. On 09/28/2021, LPA tracked the facility during the COVID-19 outbreak. Based on interviews, Facility did not have adequate supply of proper PPE for their staff to utilize while caring for residents and did not follow Covid-19 guidelines.

See attached LIC9099-D for deficiencies cited in accordance with California Code of Regulations, Title 22. Exit interview conducted. A copy of the report and appeal rights were provided to the licensee.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 24-AS-20210924153141
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SIERRA PALACE FOR ELDERLY
FACILITY NUMBER: 107200486
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/24/2021
Section Cited
CCR
87307(d)(2)
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87307 Personal Accommodations and Services (d)(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement was not met as evidenced by:
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Facility Manager and Licensee agreed to submit a revised mitigation plan to LPA by POC due date.

Licensee has a 30-day PPE supplies. LPA obseved the PPE supplies at the facility.
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Based on interviews, the Licensee did not ensure to have adequate supply of proper PPE for their staff to utilize while caring for residents and did not follow Covid-19 guidelines, which posed a potential health, safety or personal rights risk to persons in care.
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Type B
12/24/2021
Section Cited
CCR
87488.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities: (a)(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Licensee to review 87468.1 Personal Rights of Residents in All Facilities. Licensee shall submit a written letter indicating they have read and understand the regulations to CCLD by 12/24/2021.
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Based on interviews, the Licensee did not ensure to have adequate supply of proper PPE for their staff to utilize while caring for residents and did not follow Covid-19 guidelines, which posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/24/2021 and conducted by Evaluator Lady Cabrera
COMPLAINT CONTROL NUMBER: 24-AS-20210924153141

FACILITY NAME:SIERRA PALACE FOR ELDERLYFACILITY NUMBER:
107200486
ADMINISTRATOR:PERERA, NEILFACILITY TYPE:
740
ADDRESS:607 E. SIERRA AVENUETELEPHONE:
(559) 435-6345
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY:6CENSUS: 5DATE:
12/14/2021
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Elizabeth Perera, AdministratorTIME COMPLETED:
10:23 AM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Facility lacks sufficient staff to meet the residents' needs.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Lady Cabrera conducted the subsequent complaint investigation visit to the facility.

During the course of this complaint investigation LPA conducted interviews and reviewed records. Based on the interviews conducted and records review the above allegation is UNSUBSTANTIATED. There were contradicting evidence and although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted. A copy of this report was provided to Aministrator.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 3