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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107200486
Report Date: 12/28/2022
Date Signed: 12/28/2022 10:24:33 AM


Document Has Been Signed on 12/28/2022 10:24 AM - 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: 6DATE:
12/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Virginia Jimenez, ManagerTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Lady Cabrera conducted an unannounced case management visit to the facility. The purpose of the case management visit is to follow up on Special Incident Reports (SIR) submitted to CCL Office. LPA met Administrator Elizabeth Perera-Moreland and Virginia Jimenez, Manager.

SIR 1: Staff (S1) was preparing for showers, when S1 came back into the kitchen she noticed Client (C1) was eating a nectarine that he got out of fridge. Staff noticed C1 started to choke and Staff immediately called Staff (S2) and S2 started performing the Heimlich and S1 called 911. C1 then spit out the piece of nectarine.

SIR 2: On 12/01/2022, C1 was in the kitchen and got an apple from the basket located on top of kitchen counter. Staff was in the bathroom and the other caregiver was in the dining room talking to a resident, when she noticed C1 was choking. Staff started the Heimlich Maneuver and the piece of apple came out. 911 was called. The paramedics evaluated C1.

Administrator will submit requested C1’s records for review and a follow-up may be required.

Administrator was provided with a copy of this report.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 513-9832
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022
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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