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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206560
Report Date: 06/21/2024
Date Signed: 06/22/2024 08:47:24 AM


Document Has Been Signed on 06/22/2024 08:47 AM - 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 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:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:House Manager, Virginia JimenezTIME COMPLETED:
03:36 PM
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On 06/21/24 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by House Manager, Virginia Jimenez. LPA introduced self, explained reason for visit and was permitted entry into the facility.

LPA toured the facility inside and out. LPA completed a health and safety check on residents in care. 2 of 5 residents present and in rooms at time of visit. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. 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 02/07/2024. Last fire drill on 4/10/24. Resident rooms observed. Linen supplies are kept in linen closets. Sharps, chemicals and medications were located in locked cabinets. LPA observed covered patio area.

During visit the following issues were observed: screens missing on windows and in need of replacements, carpet in living room torn and in need of repair/replacement, tile in bathroom #1 and entry way broken and in need of repair/replacement, cabinets in bathroom #1 in need of paint/repair, 3 of 5 bedrooms missing night stands, bedroom #3 in need of new mattress, sharps observed in bedroom #4, crack where ceiling meets wall in bedroom #5 in need of repair, light cover missing in laundry room, light plate cover in hallway broken and in need of replacement.

LPA requested the following documents to be submitted to CCL by 6/28/24: 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 and TV's cited per Title 22. Exit interview completed with House Manager, Virginia. A copy of this report, deficiencies, TV's and appeal right provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
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 06/22/2024 08:47 AM - 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 THE ELDERLY
FACILITY NUMBER: 107206560

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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This requirement was not met as evidence by: LPA observations of screens missing on windows and in need of replacements, carpet in living room torn and in need of repair/replacement, tile in bathroom #1 and entry way broken and in need of repair/replacement, cabinets in bathroom #1 in need of paint/repair, 3 of 5 bedrooms missing night stands, bedroom #3 in need of new mattress, sharps observed in bedroom #4, crack where ceiling meets wall in bedroom #5 in need of repair, light cover missing in laundry room, light plate cover in hallway broken and in need of replacement. These pose a potential health, safety and or personal rights risk to residents in care.
POC Due Date: 07/05/2024
Plan of Correction
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Plan of correction to be submitted in writting to CCL by 6/25/24. Correction will begin and once completed pictures will be submitted to CCL as proof of correction.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
LIC809 (FAS) - (06/04)
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