<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107200486
Report Date: 02/23/2022
Date Signed: 02/23/2022 03:57:46 PM


Document Has Been Signed on 02/23/2022 03:57 PM - It Cannot Be Edited

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:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Virginia Jimenez, ManagerTIME COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Lady Cabrera arrived unannounced for an Annual Required Inspection. Administrator Elizabeth Perera was unavailable and designated Virginia Jimenez, Manager to meet with LPA. LPA stated the purpose of the visit. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point.

Facility appeared cleaned with no obstruction. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the kitchen sink. Bedrooms were checked. The exterior tour was conducted.

LPA checked residents’ medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health. Facility staff was observed with mask on. Residents wear masks when away from the community. Resident’s files have updated emergency contact information.

On 02/09/2022, CCL received a Special Incident (SIR) Report Central Valley Regional Center regarding incident that occurred on 10/29/2021. As of today’s, date, CCL did not receive an SIR from the facility of the 10/29/2021 incident. Per SIR, Client (C1) was in the dining room area went up to C2 to hug him. C2 moved his hands and C1 grabbed C2’s wheelchair. C2 became upset and grabbed C1’s wheelchair and threw him down. When C1 was on the floor, C2 hit C1 on the face. LPA requested further documents regarding the 10/29/2021 and 11/03/2021 incidents. LPA will return to facility to address any concerns after records are reviewed.

Deficiencies are being cited on the attached LIC 809-D.



Exit interview was conducted. A copy of this report, LIC809, LIC809-D and appeal rights were provided. The Licensee’s signature on this form acknowledges receipt of these documents.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 02/23/2022 03:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement was not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observations, the Licensee did not comply with the section cited above. LPA observed mold/black residue underneath kitchen sink. LPA observed black residue in the bathroom wall located in the west part of the facility with water leakage around toilet. Licensee did not ensure to maintain facility clean and safe, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2022
Plan of Correction
1
2
3
4
Licensee will repair the bathroom and underneath the kitchen sink by 03/07/2022 and provide pictures to CCL once it is repaired.
Type B
Section Cited
CCR
80061(b)
80061 Reporting Requirements (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.

This requirement was not met as evidenced by:


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and interviews, facility failed to provide unusual incident reports regarding the 10/29/2021 incident to Community Care Licensing, which poses a potential Health, Safety and Personal Rights risks to persons in care.
POC Due Date: 03/04/2022
Plan of Correction
1
2
3
4
Licensee will read requirements of 80061 Reporting Requirements. Licensee will provide written letter indicating she has read and understood the Reporting Requirements to Fresno CCL office by 03/04/2022.

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: 02/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
VISIT DATE: 02/23/2022
NARRATIVE
1
2
3
4
5
6
7
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
Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:


Residential Care Facility for the Elderly (RCFE):
· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Liability Insurance
· Copy of current Administrator Certificate
· Alternate contact information including name, telephone number, & email address.

Please submit the above forms/information to Fresno CCL by: 03/02/2022

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4