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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107200486
Report Date: 02/23/2024
Date Signed: 02/23/2024 09:40:27 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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
12/13/2023 and conducted by Evaluator Miriam Flores
COMPLAINT CONTROL NUMBER: 24-AS-20231213150724
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:
02/23/2024
UNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Lisa LunaTIME COMPLETED:
09:55 AM
ALLEGATION(S):
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Staff do not provide the proper resources to residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) M. Flores arrived at the facility unannounced for subsequent complaint inspection. LPA discussed the purpose of the visit and the elements of the allegations with House Manager, Lisa Luna. Administrator, Elizabeth gave a verbal consent for this LPA to have this inspection with House Manager, Lisa Luna. LPA delivered the following findings:

LPA, M. Flores conducted the subsequent complaint investigation visit to the facility. During the course of this complaint investigation. LPA interviewed staff on duty, obtained and reviewed facility records. It was determined based on the interviews and records review that the above allegation is SUBSTANTIATED. Staff do not provide the proper resources to resident in case. Based on evidence, facility did not have the proper personnel to meet the needs of R4 per needs identified in the care plan. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

Continue 9099D
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam FloresTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
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-20231213150724
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: SIERRA PALACE FOR ELDERLY
FACILITY NUMBER: 107200486
VISIT DATE: 02/23/2024
NARRATIVE
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California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam FloresTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20231213150724
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SIERRA PALACE FOR ELDERLY
FACILITY NUMBER: 107200486
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2024
Section Cited
CCR
87411(a)
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(a) Facility personnel shall... be sufficient in numbers...to provide the services necessary to meet resident needs... provide additional staff whenever it determines through documentation that the needs of...residents...This requirement was not met as evidenced by
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Licensee has implemented a new staff schedule to meet the one-on-one requirements as stated in the IPP for R4 as of January 1, 2024.
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The Licensee did not ensure that the facility was equipped to provide the 1 on 1 staffing for R4, as agreed on the Individual Program Plan dated 10/17/23. This poses a potential Health and Safety risk to person 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) -24-0610
LICENSING EVALUATOR NAME: Miriam FloresTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3