Sierra Palace for Elderly #2

Type of visit: Required - 1 Year

On 09/24/25 Licensing Program Analyst arrived at the facility to complete an unannounced annual visit. LPA met with Direct Support Professional, Reyna Martinez explained reason for visit and was permitted entry into the facility. House Manager, Virginia Jimenez arrived a short time later. LPA completed a tour of the facility inside and out. A health and safety check was completed on residents in care. 4 residents were present during todays visit. 4 residents with restricted health conditions. 1 resident on home health. No hospice services at this time. Pathways and doors were clear and free from obstruction. Facility was without odor. Common areas were adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. 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. The following issues were observed during today’s visit: 1 of 6 residents were observed to be bedridden without the proper fire clearance. 4 of 6 residents observed to be diabetic and staff assisting with glucose testing/medication. 3 of 3 resident records reviewed did not have the required documentation. Emergency and Disaster Plan was observed inaccurate/incomplete. No plans of care for allowable health conditions for residents requiring them. Driveway concrete was observed to be broken up and the back yard flooded due to a broken pipe. Dryer vent in need of cleaning. Back doors (2) in need of weather stripping. Bathroom shower observed dirty in need of cleaning. Bedroom #2 door plate damaged and in need of repair. Kitchen drawer and bedroom #3 dresser broken and in need of repair or replacement. Dining room blinds broken and in need of replacement. CONT... CONT... Deficiencies cited per California Code of Regulations, Title 22, on the attached 809D. If not corrected, the violation with have a direct risk to the health, safety and/or personal rights of residents in care. LPA requested the following documents to be submitted to CCL by 10/10/25: 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), a current copy of the surety bond and liability insurance in order to update the facility file. Exit interview was conducted with House Manager, Virginia. A plan of correction was developed by House Manager and reviewed by LPA. A copy of this report, deficiencies, and appeal rights were discussed and provided to House Manager.the state’s words, verbatim · CDSS document, Sep 24, 2025

Type of visit: Case Management - Incident

On 8/14/25 Licensing Program Analyst (LPA) M. Garza arrived at the facility for an unannounced case management visit. LPA met with Administrator, Elizabeth Moreland and House Manager, Virginia Jimenez, explained reason and was permitted entry into the facility. There is 1 resident present during todays visit and was observed in common area. This case management visit is being conducted due to a phone call received by a Reporting Party (RP). RP stated there was an online post indicating the facility was without air conditioning and was over 80 degrees F inside. Outside temperature was measuring at 105 degrees F on this day. O On 8/12/25 LPA received and reviewed an incident report sent to CCL. Incident report was sent on 8/11/25, via fax at 11:37 pm. Incident report indicated the facility has an air conditioning unit that was not working. It indicated A. Olsen, Director of Community Services and Supervisor, M. Halverson from Central Valley Regional Center came to the facility . Both indicated to Administrator the facility was still in compliance for the temperature inside. Interview with Administrator and House Manager confirmed the facility had a broken air conditioning unit on 8/8/25 through 8/11/25. The unit was frozen and not functioning properly causing the facililty to be hot. Administrator stated the facility has an additional unit that was still functioning and fans were brought in. Both confirmed the temperature inside was 80 degrees F during this time. Administrator indicated the unit still needs some parts/repairs and will be replaced but the unit is currently functioning. CONT... CONT... During todays visit LPA observed both thermostats measuring the inside temperature to be at 75 degrees F. Although the facility had an additional unit that was working and fans were brought in to assist in keeping the facility cool the temperature inside the facility measured above the 30 degree requirement from 8/8/25 to 8/11/25.Deficiency cited per Title 22 on attached 809D. Exit interview completed with House Manager, Virginia. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 14, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b)(2) · Plan of correction due date: Aug 22, 2025

87303 Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. This requirement was not met as evidence by records reviewed and interviews completed. The licensee did not comply with the section cited above in that the facility had a broken AC unit from 8/8/25 through 8/11/25. Inside temperature did not measure less than 30 degrees from the outside temperature in extreme heat. This poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2025

Plan of correction: Administrator contacted air conditioning services and had unit serviced. Unit is functioning currently and has a measured temperature of 75 degree F inside facility. Administrator provide a copy of receipt showing service was completed.

Type of visit: Required - 1 Year

On 09/09/2024 Licensing Program Analysts (LPA's) M. Garza and R. Bruce arrived unannounced for an annual inspection visit. LPA's were met by Direct Support Staff, Dora Bagda. LPA's introduced selves, explained reason for visit and was permitted entry into the facility. House Manager, Virginia Jimenez was contacted and arrived a short time later. Administrator, Elizabeth Moreland was contacted and arrived after Virginia LPA's completed a health and safety check on residents in care. LPA's toured the facility inside and out. Residents not present during time of visit. Pathways and doors were clear and free from obstruction. Facility was clean. 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 2/7/24. Last fire drill in April 2024. Water temperature measured 118.2 degrees F. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closet in hallway. Sharps, chemicals locked in cabinets. Medications were located in locked medication cart. The following issues were observed during visit: 1 of 5 residents rooms observed with odor of urine. No seating under covered patio area. Chemicals inside unlocked shed. Right side gate does not self latch. Light with missing bulbs exposing electrical. Pest control issue. Laundry piled in receptacle without lid. Laundry room door in need of repair or replacement. Laundry vent on roof in need of cleaning. Metal rebar sticking out of ground in need of removal. Food source does not meet regulation requirements. Door plate in R1's room missing screws. R3's bedroom door (master) missing trim. R3's light cover exposing electric. R3's bathroom door observed with a small hole in need of repair. Chemicals observed in 6 of 6 resident rooms and 3 of 3 restroom. CONT... CONT... LPA's requested the following documents to be submitted to CCL by 9/13/24: 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 cited during the inspection. Exit interview completed with Administrator, Elizabeth Moreland. A copy of this report, deficiencies, TV's and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 9, 2024

Allegation investigated: Staff did not follow client's behavior plan or provide proper support Staff did not seek medical assistance for client in a timely manner

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 and reviewed records. Based on the records reviewed, the facility failed to follow client’s behavior plan or seek medical assistance timely. 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 and appeal rights were discussed and provided to Administrator, Elizabeth Perera-Moreland, whose signature on this form confirms receipt of this document. Substantiatedthe state’s words, verbatim · CDSS document, Jul 24, 2024 · control 24-AS-20231213160739

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 seek medical assistance with resident had a change of condition, 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: Jul 24, 2024

87411(d)(3) Personnel Requirements – General - Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement was not met as evidenced by: Based on record reviewed and interviews conducted, the facility failed to follow client’s behavior plan with Regional Center, 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.

Allegation investigated: Resident was obseved to have an unexplained injury Resident beds smell like urine due to facility not have proper bedding

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 and reviewed records. Based on the records reviewed and interviews conducted, resident was observed with an unexplained injury. Based on LPA observation during the facility visit, resident’s bed smelled like urine. 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. The allegation of lack of care and supervision resulting in resident sustaining an unexplained injury is cited on Complaint #24-AS-20231213160739 Exit interview conducted and a plan of correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to Administrator Elizabeth Perera-Moreland, whose signature on this form confirms receipt of this document. Substantiatedthe state’s words, verbatim · CDSS document, Jul 24, 2024 · control 24-AS-20240327135300

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 24, 2024

87303(a) Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on LPA observation, the resident’s bedroom smelled like urine during the complaint visit, which poses a potential health and safety risk.the state’s words, verbatim · CDSS document, Jul 24, 2024

Plan of correction: Resident’s room was cleaned and bedding added. POC is cleared.

Allegation investigated: Staff sleeping while on duty Facility does not have an adequate amount of food

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, it was found that staff was asleep while on duty. LPA observe the facility did not have an adequate amount of food. 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. The allegation of staff sleeping while on duty is cited on Complaint #24-AS-20231213160739 Exit interview conducted and a plan of correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to Administrator Elizabeth Perera-Moreland, whose signature on this form confirms receipt of this document. Substantiatedthe state’s words, verbatim · CDSS document, Jul 24, 2024 · control 24-AS-20240329135433

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Jul 24, 2024

87555(a) General Food Service Requirements The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. This requirement was not met as evidenced by: Based on observation made during the tour of the facility and records reviewed, the facility did not have an adequate supply of food, which poses a potential health and safety risk.the state’s words, verbatim · CDSS document, Jul 24, 2024

Plan of correction: The facility provided documentation of adequate food supply. POC is cleared during inspection

Type of visit: Required - 1 Year

On 10/25/2023 Licensing Program Analyst (LPA) M. Garza completed an announced annual visit. LPA met with Direct Care Staff, Kathleen Welch. explained reason for visit and was permitted entry into the facility. House Manager, Virginia Jimenez and House Manager, Mary Chum was contacted and arrived a short time later. LPA completed a health and safety check on residents in care. LPA toured the facility inside and out. There was 4 of 6 residents at day program during time of visit. 2 resident present at the time of inspection observed in room and common area. 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 2/14/23. Last fire drill on 3/25/23. Water temperature measured 109.7 degrees F. During visit the following issues were observed by LPA: 2 of 6 resident rooms observed to be missing night stands. 1 of 6 rooms missing lamps. 1 of 6 missing chair. LPA requested the following documents to be submitted to CCL by 11/1/23: 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. TV's provided for the issues listed above. Due to time constraints, LPA will return at a later date for an annual continuation. Exit interview completed with House Manger, Virginia. A copy of this report given.the state’s words, verbatim · CDSS document, Oct 25, 2023