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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206560
Report Date: 06/30/2025
Date Signed: 06/30/2025 02:37:27 PM

Document Has Been Signed on 06/30/2025 02:37 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SIERRA PALACE FOR THE ELDERLYFACILITY NUMBER:
107206560
ADMINISTRATOR/
DIRECTOR:		PERERA, NEIL MANUELFACILITY TYPE:
740
ADDRESS:2060 W. MENLOTELEPHONE:
(559) 375-1917
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY: 6CENSUS: 4DATE:
06/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:04 AM
MET WITH:House Manager, Virginia JimenezTIME VISIT/
INSPECTION COMPLETED:
02:38 PM
NARRATIVE
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On 6/30/25 Licensing Program Analyst (LPA) M. Garza arrived at the facility to complete an unannounced annual visit. LPA met with House Manager, Virginia Jimenez explained reason for visit and was permitted entry into the facility. Administrator, Elizabeth Perera-Moreland was contacted, stated they were unavailable and the visit could be conducted with House Manager, Virginia. LPA completed a tour of the facility inside and out. Residents not present at time of visit. Currently there are no residents receiving hospice or home health.

Pathways and doors were clear and free from obstruction. Facility was without odor. Common areas were adequately furnished. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last serviced on 2/27/25. Resident rooms observed to have the required furnishings and with adequate lighting. Sharps, chemicals and medications were located in locked cabinets/closets and cupboards. LPA observed sufficient seating under covered patio areas.

CONT...

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/30/2025 02:37 PM - It Cannot Be Edited


Created By: Mary Garza On 06/30/2025 at 01:37 PM
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: 06/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the facility has a plan but does not have the required information listed. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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House Manager stated they will update the plan and submit to CCL for review by POC date.
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in that 1 of 4 resident rooms was observed with a 1/2 bed rail. File review showed a prescription was not found for repositioning. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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Bed railing will be removed and a a physicians order will be requested. Physicians order will be sent to CCL by POC date as proof of correction.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/30/2025 02:37 PM - It Cannot Be Edited


Created By: Mary Garza On 06/30/2025 at 01:45 PM
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: 06/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)(1)(A)
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall document, at a minimum: (A) An evaluation of the prospective resident's functional capabilities, mental condition, and social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA file reviews, the licensee did not comply with the section cited above in that 2 of 2 files reviewed did not have a pre-appraisal/functional capabilities. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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House Manager stated they will reach out to responsible parties and update files as needed. A referral for TSP was requested by Administrator.
Type B
Section Cited
CCR
80087(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in that Holes observed in bedroom #5 door in need of repair or replacements. Plug cover in bedroom #6 missing and in need of replacement. Holes in stucco on back left side of house in need of repair. Fence on left side yard leaning in need of repair. Carpet in living room observed dirty and in need of cleaning. Bedroom #4 observed with bed railing without prescription for repositioning. Vents throughout the house observed rusted in need of paint or replacement. Carpet outside bedrooms 2 & 3 observed torn in need of repair/replacement. Bedroom #1 in need of touch up paint in bedroom/bathroom. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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A plan of correction will be completed in writting. A copy will be sent to CCL to show anticipated correction dates. Pictures will be sent to CCL as proof of correction once completed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: SIERRA PALACE FOR THE ELDERLY
FACILITY NUMBER: 107206560
VISIT DATE: 06/30/2025
NARRATIVE
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CONT...

The following issues were observed during today’s visit: Holes observed in bedroom #5 door in need of repair or replacements. Plug cover in bedroom #6 missing and in need of replacement. Holes in stucco on back left side of house in need of repair. Fence on left side yard leaning in need of repair. Carpet in living room observed dirty and in need of cleaning. Bedroom #4 observed with bed railing without prescription for repositioning. Vents throughout the house observed rusted in need of paint or replacement. Carpet outside bedrooms 2 & 3 observed torn in need of repair/replacement. Bedroom #1 in need of touch up paint in bedroom/bathroom.

Deficiencies cited per California Code of Regulations, Title 22. Deficiencies are being cited on the attached 809D. If not corrected, the violations with have a direct and potential risk to the health, safety and/or personal rights of residents in care.

LPA requested the following documents to be submitted to CCL by 7/11/25: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-D), Affidavit regarding Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

Exit interview was conducted with House Manager, Virginia. A copy of this report, deficiencies, and appeal rights were discussed and provided. A plan of correction was developed by House Manager and reviewed by LPA.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC809 (FAS) - (06/04)
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