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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107200877
Report Date: 09/09/2024
Date Signed: 09/09/2024 05:06:59 PM


Document Has Been Signed on 09/09/2024 05:06 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:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:House Manager, Virginia JimenezTIME COMPLETED:
03:59 PM
NARRATIVE
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On 09/09/2024 Licensing Program Analysts (LPA's) M. Garza and R. Bruce arrived unannounced for an annual inspection visit. LPA's were met by Direct Support Staff, Dora Bagda. LPA's introduced selves, explained reason for visit and was permitted entry into the facility. House Manager, Virginia Jimenez was contacted and arrived a short time later. Administrator, Elizabeth Moreland was contacted and arrived after Virginia

LPA's completed a health and safety check on residents in care. LPA's toured the facility inside and out. Residents not present during time of visit. Pathways and doors were clear and free from obstruction. Facility was clean. 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 2/7/24. Last fire drill in April 2024. Water temperature measured 118.2 degrees F. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closet in hallway. Sharps, chemicals locked in cabinets. Medications were located in locked medication cart.

The following issues were observed during visit: 1 of 5 residents rooms observed with odor of urine.
No seating under covered patio area. Chemicals inside unlocked shed. Right side gate does not self latch. Light with missing bulbs exposing electrical. Pest control issue. Laundry piled in receptacle without lid. Laundry room door in need of repair or replacement. Laundry vent on roof in need of cleaning. Metal rebar sticking out of ground in need of removal. Food source does not meet regulation requirements. Door plate in R1's room missing screws. R3's bedroom door (master) missing trim. R3's light cover exposing electric. R3's bathroom door observed with a small hole in need of repair. Chemicals observed in 6 of 6 resident rooms and 3 of 3 restroom.

CONT...
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024
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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Document Has Been Signed on 09/09/2024 05:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 #2
FACILITY NUMBER: 107200877

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA's observed chemicals in 6 of 6 bedrooms, 3 of 3 restrooms and in shed unlocked and accesible to clients in care. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
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Chemicals will be locked and stored centrally remaining accessible to the residents as needed. Staff training to be provided to all staff. In-service sign in and training material to CCL by POC date.
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) 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 is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA’s observed 1 of 5 residents rooms observed with odor of urine. No seating under covered patio area. Right side gate does not self-latch. Light with missing bulbs exposing electrical. Pest control issue. Laundry piled in receptacle without lid. Laundry room door in need of repair or replacement. Laundry vent on roof in need of cleaning. Metal rebar sticking out of ground in need of removal. Food source does not meet regulation requirements. Door plate in R1's room missing screws. R3's bedroom door (master) missing trim. R3's light cover exposing electric. R3's bathroom door observed with a small hole in need of repair. Bedroom #3 observed with torn screen in need of replacement. This poses a potential health, safety or personal rights risk to persons in care.

POC Due Date: 09/13/2024
Plan of Correction
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Plan of correction to CCL by 9/13/24 in writting. Once corrections have been completed facility to provide pictures as verification of completion.
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: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 #2
FACILITY NUMBER: 107200877
VISIT DATE: 09/09/2024
NARRATIVE
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CONT...

LPA's requested the following documents to be submitted to CCL by 9/13/24: 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.

Deficiencies cited during the inspection. Exit interview completed with Administrator, Elizabeth Moreland. A copy of this report, deficiencies, TV's and appeal rights provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC809 (FAS) - (06/04)
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