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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107200877
Report Date: 08/29/2022
Date Signed: 08/29/2022 09:05:54 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
06/02/2022 and conducted by Evaluator Alexandria Walton
COMPLAINT CONTROL NUMBER: 24-AS-20220602085215
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: 5DATE:
08/29/2022
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Manager, Virginia JimenezTIME COMPLETED:
09:20 AM
ALLEGATION(S):
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Facility is not administering medication as ordered
Facility is in disrepair
Facility does not have a menu
INVESTIGATION FINDINGS:
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On 08/29/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings on the above allegations. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Manager, Virginia Jimenez.

Record review revealed that R1 was not administered medications as prescribed and R2 was missing 3 pills. Administrator stated that the missing pills were on a different bubble pack not in the facility. Administrator did not submit proof as requested by LPA.

LPA conducted a facility tour and observed the soven and built in microwave to be in disrepair. Administrator stated that all meals are prepared offsite. LPA informed Administrator that food preparation equipment should remain operational in case of emergencies. LPA requested to see the facility menu. Administrator stated that the facility does not have menu due to food being prepared off-site.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
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 5
Control Number 24-AS-20220602085215
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
VISIT DATE: 08/29/2022
NARRATIVE
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During the facility tour, LPA attempted to turn on the shower located in Room 6. There shower was not operational during LPA's visit. An interview with the Administrator confirmed that the shower was not operational due to the safety of residents.

Based on observation, interviews conducted and record review, the preponderance of evidence standard has been met, therefore the allegations: Facility is not administering medication as ordered, Facility is in disrepair, and Facility does not have a menu are found to be SUBSTANTIATED.

Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6, on the attached 9099D.

An exit interview was conducted. Plans of Corrections were reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed and provided to Manager, Virginia Jimenez, whose signature on this form confirms receipt of this document.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 24-AS-20220602085215
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: 08/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2022
Section Cited
CCR
87465(a)(4)
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(a) A plan for incidental medical and dental care shall be developed by each facility... by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for section 87465 are met to the Fresno CCL office by the POC due date.
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Based on observation and interview, Licensee did not ensure all residents were assisted with self-administered medications as needed when R1 was not administered medications and R2 was missing medications, which poses an immediate health and safety risk to residents in care.
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Type B
09/29/2022
Section Cited
CCR
87303(a)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by:
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Licensee agrees to replace/repair the stove, built-in microwave and shower by the POC due date and submit proof to the Fresno CCL office.
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Based on observation, Licensee did not ensure the facility was in good repair when the oven, built-microwave, and shower in R1’s bathroom was in disrepair, which poses a potential health and safety risk to residents/clients 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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 24-AS-20220602085215
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: 08/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2022
Section Cited
CCR
87555(b)(16)
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(b) The following food service requirements shall apply: …Facilities licensed for less than sixteen (16) residents shall maintain a sample menu in their file. Menus shall be made available for review by the residents or their designated representatives and the licensing agency upon request.
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for section 87555 are met to the Fresno CCL office by the POC due date.
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Based on observations and interviews, the Licensee did not ensure a menu was available to review upon request, which poses a potential health and safety risk to residents/clients 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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
06/02/2022 and conducted by Evaluator Alexandria Walton
COMPLAINT CONTROL NUMBER: 24-AS-20220602085215

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: 5DATE:
08/29/2022
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Manager, Virginia JimenezTIME COMPLETED:
09:20 AM
ALLEGATION(S):
1
2
3
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5
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9
Facility is not meeting resident's dietary needs
Uncleared adult is residing at facility
Facility does not have emergency food supplies
Facility does not provide resident with toilet paper
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 08/29/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings on the above allegations. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Manager, Virginia Jimenez.

Based on observation, interviews, and record reviews, the allegations: Facility is not meeting resident's dietary needs, Uncleared adult is residing at facility, Facility does not have emergency food supplies and Facility does not provide resident with toilet paper are UNSUBSTANTAITED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies issued during this inspection. An exit interview was conducted. A copy of this report was discussed and provided to Manager, Virginia Jimenez, whose signature on this form confirms receipt of this document.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5