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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206560
Report Date: 06/30/2025
Date Signed: 06/30/2025 03:35:17 PM

Document Has Been Signed on 06/30/2025 03:35 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 THE ELDERLYFACILITY NUMBER:
107206560
ADMINISTRATOR/
DIRECTOR:		PERERA, NEIL MANUELFACILITY TYPE:
740
ADDRESS:2060 W. MENLOTELEPHONE:
(559) 375-1917
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY: 6CENSUS: 4DATE:
06/30/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:48 PM
MET WITH:House Manager, Virginia JimenezTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 6/30/25 Licensing Program Analyst (LPA) M. Garza arrived at the facility to complete an unannounced case management visit. LPA met with House Manager, Virginia Jimenez explained reason for visit and was permitted entry into the facility. Administrator, Elizabeth Perera-Moreland was contacted, stated they were unavailable and the visit could be conducted with House Manager, Virginia. LPA completed a tour of the facility inside and out. Residents not present at time of visit. Currently there are no residents receiving hospice or home health.

This case management is being conducted for an incident report received by the department involving R1. LPA reviewed daily notes, prescription, incident report and centrally stored medication log. Incident occurred on 2/26/25 and 2/27/25. CCL received incident report on 3/14/25. Incident report stated R1 was observed with a swollen mouth on 2/26/25. R1 was asked if they were in pain and stated "no". R1 attended day program this date. On 2/27/25 R1's face remained swollen. Non-emergency EMS was contacted. No pain reported by R1 to EMS. R1 refused going to hospital. A dental appointment for R1 was scheduled 2/27/25,lk with no new findings. Antibiotics prescribed as a precautionary measure. Review of medication log shows that prescription was not given as prescribed.

Deficiencies cited for reporting requirements and medications per California Code of Regulations, Title 22. Deficiencies are being cited on the attached 809D. If not corrected, the violations with have a direct and potential risk to the health, safety and/or personal rights of residents in care.

Exit interview was conducted with House Manager, Virginia. A copy of this report, deficiencies, and appeal rights were discussed and provided. A plan of correction was developed by House Manager and reviewed by LPA.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/30/2025 03:35 PM - It Cannot Be Edited


Created By: Mary Garza On 06/30/2025 at 03:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SIERRA PALACE FOR THE ELDERLY
FACILITY NUMBER: 107206560

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/11/2025
Section Cited
CCR
80075(5)(B)

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80075 Health Related Services
(5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, providing all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.
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Administrator stated they will provide medication training to all staff. An in-service sign in sheet and training material will be provided to CCL by POC date as proof of correction.
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This requirement was not met by: LPA records review, the licensee did not comply with the section cited above in that R1 was not provided medication as per physicians orders. This posed a potential health, safety and or personal rights risk to persons in care.
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Type B
07/11/2025
Section Cited
CCR80061(b)

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80061 Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.
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Administrator stated they will provide training on reporting requirements to all staff. An in-service sign in sheet and training material will be provided to CCL by POC date as proof of correction.
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This requirement was not met by: LPA records review, the licensee did not comply with the section cited above in that incident involving R1 occurred on 2/26/25 & 2/27/25 and was not reported until 3/14/25. This posed a potential health, safety and or personal rights risk to persons 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.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2025


LIC809 (FAS) - (06/04)
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