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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206560
Report Date: 05/19/2022
Date Signed: 05/19/2022 12:54:01 PM

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
01/26/2022 and conducted by Evaluator Kamaldeep Kaur
COMPLAINT CONTROL NUMBER: 24-AS-20220126091415
FACILITY NAME:SIERRA PALACE FOR THE ELDERLYFACILITY NUMBER:
107206560
ADMINISTRATOR:PERERA, NEIL MANUELFACILITY TYPE:
740
ADDRESS:2060 W. MENLOTELEPHONE:
(559) 375-1917
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 5DATE:
05/19/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator Elizabeth Perera-MorelandTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Residents engaged in a physical altercation resulting in injuries.
Facility is not following reporting requirements.
Facility staff did not adequately supervise residents.
Facility did not seek resident medical attention.
INVESTIGATION FINDINGS:
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The Department conducted interviews and reviewed records. Based on interviews conducted with Regional Center and facility staff, facility failed to intervene in a physical altercation between R1 and R2, which resulted in R1 getting a black eye, missing teeth, and injury to his right arm. Records and Regional’s Center’s corrective action plan were also reviewed and supported that the facility failed to seek medical attention for R1 after the altercation and the incident was not reported to the Department until after regional center was made aware of the incident. The preponderance of evidence standard has been met, therefore, the above allegations are substantiated. Per Title 22, the following deficiencies are being cited on the attached 9099D. Plan of correction discussed. Appeal rights given. Exit interview completed.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda WhiteTELEPHONE: (550) 243-8080
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: (559) 341-7449
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
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-20220126091415
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 THE ELDERLY
FACILITY NUMBER: 107206560
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2022
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements - General

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:
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Administrator states staff have been trained on observation, resident’s care, and reporting requirements. Corrective action plan of training was reviewed.
***POC cleared during inspection.***
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Based on interviews conducted and records reviewed, the facility failed to intervened in a physical altercation between R1 and R2 that resulted in R1 getting a black eye, four missing teeth, and injury to his right arm. This poses an immediate health and safety risk to the clients in care.
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Type B
06/02/2022
Section Cited
CCR
87466
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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met as evidenced by:
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Administrator states staff have been trained on observation, resident’s care, and reporting requirements. Corrective action plan of training was reviewed.
***POC cleared during inspection.***
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Based on records reviewed and interviews conducted, facility failed to seek medical attention for R1 after a physical altercation with another resident, which poses a potential health and safety risk to the residents in care.
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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: Brenda WhiteTELEPHONE: (550) 243-8080
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: (559) 341-7449
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 24-AS-20220126091415
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 THE ELDERLY
FACILITY NUMBER: 107206560
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/02/2022
Section Cited
CCR
87211(a)(1)
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87211(a)(1) Reporting Requirements A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This requirement was not met as evidence by:
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Administrator states staff have been trained on observation, resident’s care, and reporting requirements. Corrective action plan of training was reviewed.
***POC cleared during inspection.***
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Based on records reviewed, the facility failed to submit an incident report of the altercation between R1 and R2 or of R1’s injuries until after the Department was notified by Regional Center, which poses a potential health and safety risk to the residents in care.
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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: Brenda WhiteTELEPHONE: (550) 243-8080
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: (559) 341-7449
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3