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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206560
Report Date: 12/02/2021
Date Signed: 12/03/2021 02:28:45 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/24/2021 and conducted by Evaluator David Ayers
COMPLAINT CONTROL NUMBER: 24-AS-20210924152010
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: 5DATE:
12/02/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Viriginia Jimenez - ManagerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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5
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7
8
9
Facility is not following COVID-19 guidelines.
Facility does not have proper PPE for staff.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this date, Licensing Program Analyst(LPA) D. Ayers arrived at the facility unannounced to deliver complaint findings. LPA met with Manager Virginia Jimenez and announced the purpose of the visit.

During the course of the investigation, the Department conducted interviews, reviewed records, and conducted facility inspections. Based off of interviews and a tour of the facility conducted on 9/28/2021, facility was not properly quarantining COVID-19 positive or exposed residents according to safety protocols. Facility did not have an adequate supply of proper PPE for their staff to utilize while caring for residents. The above allegations are Substantiated. See attached 9099-D for deficiencies cited in accordance with California Code of Regulations, Title 22. Exit interview conducted. A copy of the report and appeal rights were provided to the licensee via email.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: David Ayers
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 24-AS-20210924152010
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 ELDERLY
FACILITY NUMBER: 107206560
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2021
Section Cited
CCR
87307(d)(2)
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2
3
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7
87307 Personal Accommodations and Services (d)(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidenced by:
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3
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5
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7
Facility Manager and Licensee agreed to submit a revised mitigation plan to LPA by POC due date.
8
9
10
11
12
13
14
Based on interviews, the licensee did not comply with the section cited above for five out of five residents, which posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
12/16/2021
Section Cited
CCR
87468.1(a)(2)
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7
87468.1 Personal Rights of Residents in All Facilities: (a)(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Based on interviews, the licensee did not comply with the section cited above for five out of five residents, which posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: David Ayers
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/24/2021 and conducted by Evaluator David Ayers
COMPLAINT CONTROL NUMBER: 24-AS-20210924152010

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:
12/02/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Viriginia Jimenez - ManagerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility lacks sufficient staff to meet the residents' needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this date, Licensing Program Analyst(LPA) D. Ayers arrived at the facility unannounced to deliver complaint findings. LPA met with XXX and announced the purpose of the visit.

During the course of the investigation, the Department conducted interviews, reviewed records, and conducted facility inspections. Based off of interviews and records reviewed, the facility had sufficient staff to meet the needs of the residents. The facility had at least A copy of the report and appeal rights were provided to the licensee via email.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: David Ayers
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3