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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 10:13:04 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
03/29/2024 and conducted by Evaluator Alexandria Walton
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240329135433
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:
11:17 AM
MET WITH:Administrator Elizabeth Perera-Moreland TIME COMPLETED:
11:28 AM
ALLEGATION(S):
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Staff sleeping while on duty
Facility does not have an adequate amount of food
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, reviewed records, and toured the facility. Based on the records reviewed and interviews conducted, it was found that staff was asleep while on duty. LPA observe the facility did not have an adequate amount of food. 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 staff sleeping while on duty 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-20240329135433
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
87555(a)
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87555(a) General Food Service Requirements The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. This requirement was not met as evidenced by:
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The facility provided documentation of adequate food supply. POC is cleared during inspection
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Based on observation made during the tour of the facility and records reviewed, the facility did not have an adequate supply of food, 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
03/29/2024 and conducted by Evaluator Alexandria Walton
COMPLAINT CONTROL NUMBER: 24-AS-20240329135433

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:
11:17 AM
MET WITH:Administrator Elizabeth Perera-Moreland TIME COMPLETED:
11:28 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not assist resident with feeding
Facility does not provide nutritious meals to residents
INVESTIGATION FINDINGS:
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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.

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