Sierra Palace for the Elderly

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Administrator, Virginia Jimenez, Continual Administrator's Certification expires 02/09/2028 There are currently 4 residents who reside at this home and there is 1 resident on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, office and outdoor areas. . There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable. Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 112 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. The facility did not notify Licensing of Resident 1's Hospice initiation. Resident 1's hospice care plan was not in hospice binder (staff did provide copy before end of visit.) Staff 1 needs TB test along with health Screening. Facility window screens are not in good repair, main hallway resident bathroom faucet closest to the window has low water pressure, bathroom vanity door knobs are lose, multiple facility vents appeared to be dusty/dirty.. Resident 2 does not have required furnishings (lamp.) Facility did not have required / updated resident roster. Resident 1's medications are not documented accurately on the Centrally stored medication record. The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22. LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing. Exit interview conducted with Administrator, Virginia Jimenez, and copy of report left at facilitythe state’s words, verbatim · CDSS document, Jun 11, 2026

The state marks this report as 11 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

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... 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.the state’s words, verbatim · CDSS document, Jun 30, 2025

Type of visit: Case Management - Incident

On 6/30/25 Licensing Program Analyst (LPA) M. Garza arrived at the facility to complete an unannounced case management 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. This case management is being conducted for an incident report received by the department involving R1. LPA reviewed daily notes, prescription, incident report and centrally stored medication log. Incident occurred on 2/26/25 and 2/27/25. CCL received incident report on 3/14/25. Incident report stated R1 was observed with a swollen mouth on 2/26/25. R1 was asked if they were in pain and stated "no". R1 attended day program this date. On 2/27/25 R1's face remained swollen. Non-emergency EMS was contacted. No pain reported by R1 to EMS. R1 refused going to hospital. A dental appointment for R1 was scheduled 2/27/25,lk with no new findings. Antibiotics prescribed as a precautionary measure. Review of medication log shows that prescription was not given as prescribed. Deficiencies cited for reporting requirements and medications 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. 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.the state’s words, verbatim · CDSS document, Jun 30, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80075(5)(B) · Plan of correction due date: Jul 11, 2025

80075 Health Related Services (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, providing all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met by: LPA records review, the licensee did not comply with the section cited above in that R1 was not provided medication as per physicians orders. This posed a potential health, safety and or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 30, 2025

Plan of correction: Administrator stated they will provide medication training to all staff. An in-service sign in sheet and training material will be provided to CCL by POC date as proof of correction.

From the deficiency page — Deficiency type: Type B · Section cited: CCR80061(b) · Plan of correction due date: Jul 11, 2025

80061 Reporting Requirements (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. This requirement was not met by: LPA records review, the licensee did not comply with the section cited above in that incident involving R1 occurred on 2/26/25 & 2/27/25 and was not reported until 3/14/25. This posed a potential health, safety and or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 30, 2025

Plan of correction: Administrator stated they will provide training on reporting requirements to all staff. An in-service sign in sheet and training material will be provided to CCL by POC date as proof of correction.

Allegation investigated: Staff do not transport residents to hospital as needed

On this date, Licensing Program Analyst (LPA) A. Walton and Licensing Program Manager (LPM) S. Moua met with Administrator Elizabeth Perera-Moreland to deliver findings for the above allegations. The Department conducted interviews, reviewed records, and toured the facility. Based on the records reviewed and interviews conducted, facility staff did not transport the resident to the hospital. The preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. See citations on the attached LIC. 9099D. Exit interview conducted and a plan of correction was reviewed and developed. A copy of this report was discussed and provided to Administrator Elizabeth Perera-Moreland, whose signature on this form confirm receipt of this document. Substantiatedthe state’s words, verbatim · CDSS document, Jul 24, 2024 · control 24-AS-20231213131331

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jul 24, 2024

87465(a)(1) Incidental Medical and Dental Care - The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on records reviewed and interviews conducted, the facility failed to ensure resident was transported to the hospital, which poses a potential health and safety risk.the state’s words, verbatim · CDSS document, Jul 24, 2024

Plan of correction: Facility completed CAP (Correction Action Plan) with regional center. Plan was reviewed. POC is cleared on this date.

Type of visit: Required - 1 Year

On 06/21/24 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by House Manager, Virginia Jimenez. LPA introduced self, explained reason for visit and was permitted entry into the facility. LPA toured the facility inside and out. LPA completed a health and safety check on residents in care. 2 of 5 residents present and in rooms at time of visit. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last serviced 02/07/2024. Last fire drill on 4/10/24. Resident rooms observed. Linen supplies are kept in linen closets. Sharps, chemicals and medications were located in locked cabinets. LPA observed covered patio area. During visit the following issues were observed: screens missing on windows and in need of replacements, carpet in living room torn and in need of repair/replacement, tile in bathroom #1 and entry way broken and in need of repair/replacement, cabinets in bathroom #1 in need of paint/repair, 3 of 5 bedrooms missing night stands, bedroom #3 in need of new mattress, sharps observed in bedroom #4, crack where ceiling meets wall in bedroom #5 in need of repair, light cover missing in laundry room, light plate cover in hallway broken and in need of replacement. LPA requested the following documents to be submitted to CCL by 6/28/24: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), 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. Deficiencies and TV's cited per Title 22. Exit interview completed with House Manager, Virginia. A copy of this report, deficiencies, TV's and appeal right provided.the state’s words, verbatim · CDSS document, Jun 21, 2024