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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107200877
Report Date: 10/25/2023
Date Signed: 10/25/2023 12:47:47 PM


Document Has Been Signed on 10/25/2023 12:47 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



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:
10/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:House Manager, Virginia JimenezTIME COMPLETED:
12:58 PM
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On 10/25/2023 Licensing Program Analyst (LPA) M. Garza completed an announced annual visit. LPA met with Direct Care Staff, Kathleen Welch. explained reason for visit and was permitted entry into the facility. House Manager, Virginia Jimenez and House Manager, Mary Chum was contacted and arrived a short time later.

LPA completed a health and safety check on residents in care. LPA toured the facility inside and out. There was 4 of 6 residents at day program during time of visit. 2 resident present at the time of inspection observed in room and common area. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last serviced 2/14/23. Last fire drill on 3/25/23. Water temperature measured 109.7 degrees F.


During visit the following issues were observed by LPA: 2 of 6 resident rooms observed to be missing night stands. 1 of 6 rooms missing lamps. 1 of 6 missing chair.



LPA requested the following documents to be submitted to CCL by 11/1/23: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Affidavit regarding Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

TV's provided for the issues listed above. Due to time constraints, LPA will return at a later date for an annual continuation. Exit interview completed with House Manger, Virginia. A copy of this report given.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
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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