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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107200877
Report Date: 08/30/2021
Date Signed: 08/30/2021 04:33:27 PM

Document Has Been Signed on 08/30/2021 04:33 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
CCLD Regional Office, 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:
08/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Mary ChumTIME COMPLETED:
02:30 PM
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On this date, Licensing Program Analyst(LPA) D. Ayers arrived at the facility unannounced to conduct a Required Annual Inspection. LPA met with Manager Mary Chum. Administrator certificate is current with renewal date 8/13/2022.

LPA toured facility inside and out. All passageways and exits were clear and free from obstruction. Facility was adequately furnished and lit. Fire extinguishers had current service tag dates. Facility had smoke detectors in hallways and bedrooms which were operational. LPA observed all hazardous materials and cleaning supplies to be secured in locked storage cabinets in the laundry room. Medications were kept in a locked cart, and medications appeared to be administered properly. LPA observed a seven day supply of nonperishable food stuffs and a two day supply of perishable food stuffs which were stored properly. LPA toured resident bedrooms and bathrooms. Bedrooms were adequately furnished and lit. Bathrooms were clean, odor free, and had secure grab bars and nonskid mats in showers.

LPA and Manager reviewed infection control guidelines and best practices. No deficiencies cited during the inspection. Exit interview conducted. A copy of the report was provided to the licensee via email.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: David Ayers
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2021
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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