Inspection Reports for Northwest Villa
542 W Browning Ave, Fresno, CA 93704, CA, 93704
Back to Facility ProfileInspection Report Summary
Most inspections found deficiencies related primarily to medication management, staff training, and safety issues such as unsecured medications and improper storage of chemicals. Several complaint investigations were unsubstantiated, though one complaint was substantiated in December 2024 for medication management violations involving medications of former residents and over-the-counter drugs given without prescriptions. The facility has not faced fines or enforcement actions like license suspensions, but inspectors noted repeated issues with incomplete documentation and safety risks. The most recent report from October 2, 2025, cited multiple deficiencies including unsecured medications posing immediate risks and incomplete resident and staff records. Compared to earlier reports, the facility’s issues appear consistent without clear improvement or worsening trends.
Deficiencies per Year
16
12
8
4
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 16
Oct 2, 2025
Visit Reason
The inspection was an unannounced required annual visit conducted to evaluate compliance with licensing requirements.
Findings
The facility was generally clean, in good repair, and maintained at a comfortable temperature. However, multiple deficiencies were cited including unsecured medications and chemicals, incomplete medication orders and records, lack of staff training and certifications, maintenance issues, missing resident documentation, and failure to submit required incident reports.
Severity Breakdown
Type A: 5
Type B: 11
Deficiencies (16)
| Description | Severity |
|---|---|
| Multiple medications stored under staff bathroom sink unlocked, posing immediate health and safety risk. | Type A |
| Medication Medihoney gel administered without doctor's orders. | Type A |
| Medications Ferrous Sulfate and Melatonin 10mg not administered as directed by physician. | Type A |
| Staff files lacked current First Aid certification. | Type A |
| Cleaning solutions, chemicals, paint cans, and gardening tools stored unlocked and accessible to residents. | Type A |
| Personnel files for Administrator and staff member S3 not maintained at facility. | Type B |
| Centrally stored medication records incomplete for several residents. | Type B |
| Hole in wall by front door and disrepair under staff bathroom sink. | Type B |
| Failure to submit written report within 7 days for hospital incident involving resident R5. | Type B |
| Staff files lacked proper documentation and required training records. | Type B |
| Resident R1 lacked tuberculosis test result on file. | Type B |
| Emergency disaster drills not completed quarterly or documented; last drill in 02/2025. | Type B |
| Resident R1 used half rail bed without physician's order. | Type B |
| Resident R1's medication Melatonin 5mg not recorded in MAR. | Type B |
| Facility did not provide or train staff on use of Hoyer lift for hospice resident R1. | Type B |
| Resident R3 lacked appraisal (Lic 603) and needs and services plan (Lic 625) on file. | Type B |
Report Facts
Capacity: 6
Census: 6
Plan of Correction Due Dates: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shailesh Patel | Administrator | Met during inspection and involved in observations and corrections |
| Mai Yang | Licensing Program Analyst | Conducted the inspection |
| Rajat Roychoudhury | Licensee | Arrived during inspection |
Inspection Report
Census: 6
Capacity: 6
Deficiencies: 0
Jul 14, 2025
Visit Reason
The visit was an unannounced Case Management - Health Checks inspection conducted by the Licensing Program Analyst to evaluate the facility's compliance with licensing requirements.
Findings
The Licensing Program Analyst observed safety locks on exit doors, unlocked cleaning supplies with child safety locks on the cabinet, medications accessible to all residents in a resident room, and items blocking doors/pathways. A hospice care plan was reviewed that was created at another location. Deficiencies will be issued at a later date.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shailesh Patel | Administrator | Met with Licensing Program Analyst during the inspection visit. |
| Shawna Doucette | Licensing Program Analyst | Conducted the unannounced Case Management - Health Checks inspection. |
Inspection Report
Census: 6
Capacity: 6
Deficiencies: 0
Jan 27, 2025
Visit Reason
An informal office meeting was conducted at the Regional Office with the Administrator and Licensee to address concerns regarding facility operations.
Findings
The discussion emphasized that compliance requires proactive adherence to Title 22 regulations beyond just completing Plans of Correction (POCs). The Licensee declined TSP services, which is not mandatory, and was reminded of responsibilities including maintaining active certification and understanding regulations. Continued non-compliance may result in administrative actions such as license revocation or exclusion of staff.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Minakshi Roychoudhury | Administrator | Met with during the informal office meeting addressing facility operations. |
| Rajat Roychoudhury | Licensee | Present during the informal office meeting addressing facility operations. |
| Shailesh Patel | Administrator | Present during the informal office meeting addressing facility operations. |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 2
Dec 19, 2024
Visit Reason
The inspection was conducted to issue citations found during the investigation of complaint #20241108113724 related to medication management deficiencies.
Findings
The Licensing Program Analyst found multiple medications belonging to a former resident that were not destroyed or returned, and observed over-the-counter medications stored and administered without prescriptions or physician orders. Deficiencies were cited under California Code of Regulations, Title 22, Division 6.
Complaint Details
The visit was complaint-related, investigating complaint #20241108113724. The complaint was substantiated with citations issued for medication management violations.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Medication belonging to a resident who no longer resides in the facility was co-mingled with current resident medication, posing an immediate health and safety risk. | Type A |
| Over-the-counter medication was stored in the facility and administered without a prescription from a physician. | Type A |
Report Facts
Capacity: 6
Census: 6
Plan of Correction Due Date: Dec 20, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Minakshi Roychoudhury | Administrator | Met with Licensing Program Analyst during inspection and received report |
| Alexandria Walton | Licensing Program Analyst | Conducted the inspection and authored the report |
| Melinda Hoffmann | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 0
Dec 19, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-11-08 regarding staff interactions, medical attention, temperature control, food service, administrator management, and facility condition.
Findings
The investigation found the facility to be clean, at a comfortable temperature, in good repair, with adequate food supply, timely medical attention, and sufficient administrator management time. All allegations were unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated as there was not a preponderance of evidence to prove the alleged violations occurred. No deficiencies were issued.
Report Facts
Capacity: 6
Census: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Minakshi Roychoudhury | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Alexandria Walton | Licensing Program Analyst | Conducted the complaint investigation |
| Melinda Hoffmann | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 5
Sep 17, 2024
Visit Reason
The inspection was an unannounced annual inspection conducted by the Licensing Program Analyst to evaluate compliance with applicable regulations.
Findings
The inspection found deficiencies including incomplete resident needs and services plans, incomplete staff personnel records, lack of documentation for staff training, improper storage of disinfectants accessible to residents, outdated fire extinguisher servicing, and use of safety locks on exit doors preventing resident egress. Plans of correction were developed and some deficiencies were corrected during the inspection.
Severity Breakdown
Type A: 3
Type B: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| A bottle of disinfectant (Comet) was observed under the sink in the resident bathroom accessible to residents. | Type A |
| Fire extinguisher was last serviced on 04/10/2023, which poses an immediate health, safety or personal rights risk. | Type A |
| Complete personnel records were not maintained for facility staff. | Type B |
| Personnel training documentation was not observed on file. | Type B |
| Additional safety locks were placed on two exit doors preventing residents from leaving. | Type A |
Report Facts
Residents without needs and services plan: 3
Facility census: 6
Facility capacity: 6
Fire extinguisher last serviced date: Apr 10, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rajat Choudary | Licensee | Met with Licensing Program Analyst during inspection |
| Shailesh Patel | Administrator | Met with Licensing Program Analyst during inspection and received report |
| Alexandria Walton | Licensing Program Analyst | Conducted the inspection and authored the report |
| Melinda Hoffmann | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Original Licensing
Census: 3
Capacity: 6
Deficiencies: 0
Oct 2, 2023
Visit Reason
The inspection was a pre-licensing, unannounced visit conducted as a change of ownership inspection for the facility.
Findings
The facility met all pre-licensing requirements, including adequate furnishings, safety measures, and proper storage of medications and cleaning supplies. The fire clearance was granted for 6 residents, and all safety equipment was operational.
Report Facts
Facility capacity: 6
Resident census: 3
Fire extinguisher service date: Apr 10, 2023
Hot water temperature range: 109
Hot water temperature range: 114.7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Minakshi Roychoudhury | Administrator | Met with Licensing Program Analyst during inspection |
| Rajat Roychoudhury | Licensee | Met with Licensing Program Analyst during inspection |
| Shailesh Patel | Administrator | Met with Licensing Program Analyst during inspection |
| Alexandria Walton | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Melinda Hoffmann | Licensing Program Manager | Named in report header |
Inspection Report
Original Licensing
Census: 3
Capacity: 6
Deficiencies: 0
Sep 11, 2023
Visit Reason
The visit was conducted as part of the original licensing process (CHOW application) for the Northwest Villa facility to verify compliance with community care facility licensing laws.
Findings
The applicant and administrator demonstrated understanding of licensing laws, facility operation, admission policies, staffing requirements, emergency preparedness, complaints reporting, and pre-licensing readiness. Identification was verified and required documentation obtained.
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