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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107200877
Report Date: 10/05/2022
Date Signed: 10/07/2022 11:11:07 AM

Document Has Been Signed on 10/07/2022 11:11 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
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:
10/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Virginia Jimenez, Manager TIME COMPLETED:
04:45 PM
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On 10/05//22, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct the Infection Control Inspection. LPA met with Manager. LPA entered through the central entry point and COVID precautionary measures were taken prior to entry.

Facility Mitigation plan has been submitted to CCL. Infection control procedures described in the plan which were observed and reviewed by LPA include: Daily symptoms screenings (for staff, persons in care and visitors), testing, visitation, quarantine/isolation procedures, emergency staffing plan, PPE storage, use and training, as well as daily infection control procedures. Administrator is identified as the Infection Control Lead for the facility.

LPA toured the facility inside and out. Postings to encourage face coverings and hand washing were observed. Furniture in common and dining areas are spaced to promote distancing. Staff were all observed wearing face coverings. Facility has multiple designated visitation areas available. LPA observed 30-day medication supply and PPE accessible to staff. Common and resident bathroom sinks are stocked with liquid soap and paper towels for hand washing.

Through LPA’s observations, documentation review and interview with Manager, the required infection control practices are found to be in compliance. No deficiencies cited on today’s inspection.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2022
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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