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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206560
Report Date: 05/28/2021
Date Signed: 05/28/2021 03:31:56 PM

Document Has Been Signed on 05/28/2021 03:31 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 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:
05/28/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Virginia Jiminez- ManagerTIME COMPLETED:
12:30 PM
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On this date, Licensing Program Analyst(LPA) D. Ayers arrived at the facility unannounced to conduct a Proof of Correction inspection. LPA met with Manager Virginia Jiminez and announced the purpose of the visit. This visit was a follow-up on deficiencies cited during a Required Annual inspection on 5/19/2021.

LPA observed the bedroom of Resident 1 (R1) to have all required furnishings and to be clean and odor free. This deficiency is cleared. A copy of the report was provided to the licensee via email. Exit interview conducted.

SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: David Ayers
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2021
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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