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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206560
Report Date: 05/19/2021
Date Signed: 06/01/2021 09:26:46 AM

Document Has Been Signed on 06/01/2021 09:26 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 THE ELDERLYFACILITY NUMBER:
107206560
ADMINISTRATOR:PERERA, NEIL MANUELFACILITY TYPE:
740
ADDRESS:2060 W. MENLOTELEPHONE:
(559) 375-1917
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY: 6CENSUS: 6DATE:
05/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Virginia Jiminez-ManagerTIME COMPLETED:
02:30 PM
NARRATIVE
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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 Virginia Jiminez and announced the purpose of the inspection. Manager contacted Licensee/Administrator Elizabeth Moreland, who agreed that Manager would represent the licensee during the inspection.

LPA toured the facility inside and outside. All passageways and exits were clear and free from obstruction. LPA and Manager reviewed infection control measures and guidelines. Resident bathrooms were clean and fixtures were functional, with non-skid mats and secure grab bars installed. Outdoor area was free from hazards and provided adequate seating for residents. The fence gate had a self latching mechanism.

At 2:00 PM, in the northwestern-most bedroom in which Resident 1(R1) resides, LPA observed multiple deficiencies. There was no light source in the bedroom: the ceiling light fixture had been removed and there were exposed wires protruding from the opening. Two screws were protruding from the wall above R1's bed. At least seven nails with metal picture hangers were also protruding from the wall in various places at chest and head height on the wall. LPA observed there to be significant dust, dirt, and debris under the bed of R1. R1's chest of drawers was broken and chipped in several spots, presenting sharp and jagged edges. See attached 809D for deficiencies cited in accordance with Title 22 California Code of Regulations.

A copy of the report was provided to the licensee. Exit interview conducted.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: David Ayers
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2021
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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Document Has Been Signed on 06/01/2021 09:26 AM - It Cannot Be Edited


Created By: David Ayers On 05/21/2021 at 08:46 AM
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: 05/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(2)
87307 Personal Accomodations and Services: (d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on obervation and photographs taken, the licensee did not comply with the section cited above in one out of six bedrooms, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2021
Plan of Correction
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Facility Manager agreed to have staff conduct a deep cleaning of R1's bedroom and to remove all screws and nails from the walls.
Type B
Section Cited
CCR
87307(a)(3)(B)
87307 Personal Accomodations and Services: (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply. (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and photographs, the licensee did not comply with the section cited above in one out of six bedrooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2021
Plan of Correction
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Facility Manager agreed to provide all required furnishings for the bedroom of R1.
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:Andy Xiong
LICENSING EVALUATOR NAME:David Ayers
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2021


LIC809 (FAS) - (06/04)
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