Inspection Reports for
Summerfield of Fresno

The visit was triggered by complaint #24-AS-20250728163307. The complaint investigation found deficiencies including failure to report incidents of resident elopement and safety issues with locked gates and delayed egress doors.

The inspection found multiple deficiencies including padlocks on all perimeter gates without proper fire clearance, a delayed egress door that did not open within the required time, and failure to report incidents of a resident eloping. Immediate civil penalties were assessed for some violations.

The visit was triggered by deficiencies observed during a complaint visit #24-AS-20251118140904 conducted on the same date.

The visit found that staff member S1 was working without fingerprint clearance and staff member S2 was working without being associated with the facility. Immediate civil penalties were assessed for both violations.

The complaint was substantiated based on records reviewed, interviews, and observations. The preponderance of evidence standard was met per Title 22. Deficiencies were issued on complaint #24-AS-20250306091730.

The investigation substantiated the allegations including worsening of a resident's wound due to staff neglect, improper assistance with dental prosthetics, failure to change resident clothing, failure to safeguard personal belongings, and failure to assist with meals. Deficiencies were issued and a plan of correction was made.

The Department received 14 complaints over 6 months alleging concerns related to care and supervision, staffing, resident hygiene, a Scabies outbreak, staff training, and food. Allegations where the preponderance of evidence was met were substantiated. Civil penalties were issued.

The Department received 14 complaints over 6 months alleging issues related to care and supervision, staffing, resident hygiene, a Scabies outbreak, staff training, and food. Case management deficiencies were also cited, including Reporting Requirements, Fire Clearance with Civil Penalty, and Reappraisals. Allegations with a preponderance of evidence were substantiated and civil penalties were issued.

The visit was triggered by observations made during a complaint investigation (#24-AS-20250714144938) conducted on 7/15/2025.

The inspection found that Resident R2, with a history of anxiety/aggression, became verbally aggressive on 7/14/2025 and did not have a recent needs and service plan/reappraisal completed within the last year as required by regulation. A deficiency was cited for this issue.

The complaint was substantiated based on evidence gathered during the unannounced visit. The allegations met the preponderance of evidence standard per Title 22. A plan of correction was provided by the Executive Director and reviewed by the Licensing Program Analyst.

The investigation substantiated the allegations that staff left a resident in a wheelchair overnight and that there was inadequate supervision to manage behavioral issues, including a resident becoming verbally aggressive. Deficiencies were cited related to insufficient staffing and failure to meet residents' personal rights and care needs.

This case management visit was conducted based on observations made during a complaint visit on 07/12/2025. Deficiencies cited were related to immediate health, safety, and personal rights risks to residents.

The inspection found that a broom was jammed in the Garden Kitchenette door handle preventing access, delayed egress doors took longer than allowed to unlock, and perimeter gates were locked with chains and padlocks, posing immediate health, safety, and personal rights risks to residents.

The complaint investigation was substantiated based on evidence including record reviews and interviews. Allegations involved failure to seek medical attention after a resident fall, failure to follow a resident's diet, and failure to administer medications as prescribed.

The investigation substantiated the allegations that staff failed to seek timely medical attention for a resident after a fall, did not consistently follow a resident's prescribed pureed diet, and failed to administer prescribed medications on specified dates. Deficiencies were cited posing direct health, safety, and personal rights risks to residents.

The complaint alleging inappropriate restraint of a resident was substantiated based on evidence including observations, interviews, and documentation review.

The investigation substantiated the allegation that a resident was restrained using a soft tie without a physician's prescription, posing potential health, safety, and personal rights risks. Documentation review, observations, and interviews confirmed noncompliance with Title 22 regulations.

The visit was complaint-related, investigating incidents involving residents R1, R2, and R3. The complaint was substantiated by observations and record reviews showing failure to report incidents to CCL.

The inspection found that incidents involving residents R1, R2, and R3 were not reported to the Community Care Licensing (CCL) as required. These incidents included a skin tear injury, multiple falls requiring EMS transport, and skin irritation, all lacking proper special incident reports.

This case management visit was conducted in association with complaint #24-AS-20240906130954. The deficiency related to failure to obtain timely medical care was substantiated.

The investigation found that the facility failed to obtain medical care for resident R1 in a timely manner, resulting in R1 being placed on hospice and passing. Deficiencies were cited per Title 22.

The complaint was substantiated based on the preponderance of evidence standard per Title 22. The allegation involved staff not preventing a resident from physically assaulting others. Four incidents were documented on 8/8/24, 9/6/24, 9/15/24, and 10/6/24.

The investigation substantiated the allegation that staff failed to prevent resident R1 from physically assaulting other residents. Records showed R1 had aggressive behaviors and was involved in 4 incidents within 2 months, posing a risk to other residents.

The facility was generally clean and safe with adequate furnishings and safety equipment; however, multiple deficiencies were noted including unlocked chemicals in a resident room, sagging mattress, torn carpet, broken cabinet handle, unclean toilet, debris on courtyard sidewalk, and other maintenance and cleanliness issues throughout the facility.

The complaint investigation was substantiated based on evidence including interviews, record reviews, observations, and tours conducted on multiple dates. The allegations involved lack of resident supervision, unmet personal care needs, inadequate staff training, failure to safeguard personal belongings, and hazardous items accessible to residents.

The investigation substantiated all allegations, finding insufficient staff coverage during the night shift, unmet personal care needs, inadequate staff training, missing resident supplies, and hazardous items accessible to residents. Deficiencies were cited under multiple California Code of Regulations sections with plans of correction required.

The complaint was substantiated based on the preponderance of evidence standard per Title 22. The allegation was that staff did not prevent an outbreak of scabies.

The investigation found that the facility had an outbreak in one of four wings, but at the time of the visit, no residents were presenting symptoms or being treated. The allegation was substantiated and deficiencies were issued related to infection control requirements.

The complaint alleged the facility did not respond to changes in the resident's health and was not consistently communicating with the responsible party, providing inconsistent information. The first allegation was unsubstantiated; the second was substantiated.

The investigation found one allegation unsubstantiated regarding the facility's response to changes in Resident 1's health, but substantiated that the facility did not consistently communicate with the responsible party and provided inconsistent information. Deficiencies were cited related to failure to inform and communicate with representatives as required by California Code of Regulations.

The complaint was substantiated. Allegations included medication errors, inadequate staff training, resident elopement, inadequate supervision, and improper care. The investigation confirmed multiple deficiencies including medication errors, lack of training, elopement incident, and inadequate care and supervision.

The investigation found multiple medication administration errors, inadequate staff training including improper use of Hoyer lifts, a resident eloped unnoticed posing immediate health and safety risks, inadequate supervision due to understaffing, failure to provide medication to three residents, failure to provide showers and grooming for at least six residents, and untreated wounds on a resident.