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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 10:14:07 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
03/27/2024 and conducted by Evaluator Alexandria Walton
COMPLAINT CONTROL NUMBER: 24-AS-20240327135300
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:
11:06 AM
MET WITH:Administrator Elizabeth Perera-Moreland TIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Resident was obseved to have an unexplained injury
Resident beds smell like urine due to facility not have proper bedding
INVESTIGATION FINDINGS:
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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 and interviews conducted, resident was observed with an unexplained injury. Based on LPA observation during the facility visit, resident’s bed smelled like urine. 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. The allegation of lack of care and supervision resulting in resident sustaining an unexplained injury is cited on Complaint #24-AS-20231213160739

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-20240327135300
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
87303(a)
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87303(a) Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:
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Resident’s room was cleaned and bedding added. POC is cleared.
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Based on LPA observation, the resident’s bedroom smelled like urine during the complaint visit, 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
03/27/2024 and conducted by Evaluator Alexandria Walton
COMPLAINT CONTROL NUMBER: 24-AS-20240327135300

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:
11:06 AM
MET WITH:Administrator Elizabeth Perera-Moreland TIME COMPLETED:
11:15 AM
ALLEGATION(S):
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9
Staff is verbally abusive to residents
INVESTIGATION FINDINGS:
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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.

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