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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107200877
Report Date: 07/24/2024
Date Signed: 08/20/2024 10:15:51 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
12/13/2023 and conducted by Evaluator Alexandria Walton
COMPLAINT CONTROL NUMBER: 24-AS-20231213160739
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:
07/24/2024
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Administrator Elizabeth Perera-Moreland TIME COMPLETED:
11:01 AM
ALLEGATION(S):
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9
Staff did not follow client's behavior plan or provide proper support
Staff did not seek medical assistance for client in a timely manner
INVESTIGATION FINDINGS:
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10
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13
On this date, Licensing Program Analyst (LPA) A. Walton and Licensing Program Manager (LPM) S. Moua met with Administrator Elizabeth Perera-Moreland to deliver findings for the above allegations.

The Department conducted interviews and reviewed records. Based on the records reviewed, the facility failed to follow client’s behavior plan or seek medical assistance timely. The preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. See citations on the attached LIC. 9099D.

Exit interview conducted and a plan of correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to Administrator, Elizabeth Perera-Moreland, whose signature on this form confirms receipt of this document.
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: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
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-20231213160739
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: 07/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/24/2024
Section Cited
CCR
87465(a)(1)
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87465(a)(1) Incidental Medical and Dental Care - The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:
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7
Facility completed CAP (Correction Action Plan) with regional center. Plan was reviewed. POC is cleared on this date.
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9
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14
Based on records reviewed and interviews conducted, the facility failed to seek medical assistance with resident had a change of condition, which poses a potential health and safety risk.
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Type B
07/24/2024
Section Cited
CCR
87411(d)(3)
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87411(d)(3) Personnel Requirements – General - Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement was not met as evidenced by:
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Facility completed CAP (Correction Action Plan) with regional center. Plan was reviewed. POC is cleared on this date.
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Based on record reviewed and interviews conducted, the facility failed to follow client’s behavior plan with Regional Center, which poses a potential health and safety risk.
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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: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
12/13/2023 and conducted by Evaluator Alexandria Walton
COMPLAINT CONTROL NUMBER: 24-AS-20231213160739

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:
07/24/2024
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Administrator Elizabeth Perera-Moreland TIME COMPLETED:
11:01 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff forced client to attend day program despite client refusal
Staff forced client to shower despite refusal
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this date, Licensing Program Analyst (LPA) A. Walton and Licensing Program Manager (LPM) S. Moua met with Administrator Elizabeth Perera-Moreland to deliver findings for the above allegations.

The Department conducted interviews and reviewed records. Based on the interviews conducted and records reviewed, residents denied the allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is Unsubstantiated.

No deficiencies issued. Exit interview conducted. A copy of this report was discussed and provided to Administrator, Elizabeth Perera-Moreland, 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: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
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 3