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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107200877
Report Date: 10/05/2022
Date Signed: 10/07/2022 11:10:42 AM

Substantiated


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
06/13/2022 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20220613090727
FACILITY NAME:SIERRA PALACE FOR ELDERLY #2FACILITY NUMBER:
107200877
ADMINISTRATOR:PERERA, NEIL MANUELFACILITY TYPE:
740
ADDRESS:1492 W. BULLARDTELEPHONE:
(559) 435-6345
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 6DATE:
10/05/2022
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Virginia Jimenez, ManagerTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not have required training
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/05/22, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver findings on the above allegation. LPA was greeted by Manager Virginia Jimenez, stated the purpose of the visit and was allowed entry into the facility.

During the investigation, LPA reviewed training records for staff. Based on LPAs observation of records review, staff do not have the required training hours to care for residents.

The preponderance of evidence standard has been met, therefore, the above allegation is found to be Substantiated. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D.

An exit interview was conducted with Administrator via telephone. A copy of this report and appeal rights were discussed and provided to Manager. A plan of correction was developed by Administrator and reviewed with LPA.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
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 4
Control Number 24-AS-20220613090727
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 #2
FACILITY NUMBER: 107200877
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2022
Section Cited
CCR
87411(c)(3)(A)
1
2
3
4
5
6
7
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(3) The training shall include, but not be limited to, the following:(A) The aging process and physical limitations and special needs of the elderly.

1
2
3
4
5
6
7
Administrator will provide LPA a training date when all staff will be scheduled for required training by POC date. Administrator will have training completed within 30 calendar days.
8
9
10
11
12
13
14
This requirement was not met as evidenced by LPAs records review of staff training records. Records provided were medication management training only, and records were outdated. If not corrected, this poses an immediate risk to the health and safety of residents in care.

8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
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
06/13/2022 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20220613090727

FACILITY NAME:SIERRA PALACE FOR ELDERLY #2FACILITY NUMBER:
107200877
ADMINISTRATOR:PERERA, NEIL MANUELFACILITY TYPE:
740
ADDRESS:1492 W. BULLARDTELEPHONE:
(559) 435-6345
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 6DATE:
10/05/2022
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Virginia Jimenez, ManagerTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident's needs are not being met, resulting in several hospitalizations
Resident is not being allowed visitors
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/05/22, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver findings on the above allegations. LPA was greeted by Manager Virginia Jimenez, stated the purpose of the visit and was allowed entry into the facility.

During the investigation, LPA reviewed medical records for Resident R1. Records show facility sought medical attention for R1 on multiple occassions. R1's health has declined with age and has since been relocated due to a higher level of care.

LPA reviewed vistor's sign in sheet and conducted interviews. LPA observed a few visitor entries for some of the residents in 2021 and 2022. Not all resident's in care have visitors that come to the facility to visit.

Although the allegations may have happened, there is not a preponderance of evidence to prove that the alleged violations occurred, therefore the allegations are Unsubstantiated. Exit interview conducted and copy of report was left with Manager. No deficiencies cited.


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
06/13/2022 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20220613090727

FACILITY NAME:SIERRA PALACE FOR ELDERLY #2FACILITY NUMBER:
107200877
ADMINISTRATOR:PERERA, NEIL MANUELFACILITY TYPE:
740
ADDRESS:1492 W. BULLARDTELEPHONE:
(559) 435-6345
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 6DATE:
10/05/2022
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Virginia Jimenez, ManagerTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident’s personal belongings are missing
Resident’s medications are being mismanaged
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/05/22, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to deliver findings on the above allegations. LPA was greeted by caregivers, stated the purpose of the visit and was allowed entry into the facility.

During the investigation, LPA reviewed resident and facility records for Resident R1. LIC 621 (Client/Resident personal property and valuables log), show 2 pages of detailed inventory items. Reporting party was unable to provide what specifically was missing in the inventory.

LPA reviewed Centrally Stored Medication Destruction Records, Medication Administration Records and observed R1's medications in bubble packs in a locked med cart with an appropriate medication count.

Through evidence of records review, the complaint allegations are Unfounded, meaning that the allegations are false, could not have happened and or is without reasonable basis. The complaint has been dismissed. Exit interview conducted and a copy of this report was provided to Manager.


Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
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 4