Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally good compliance with regulations. The facility had isolated issues primarily related to medication management, including two instances where medications were not administered as ordered, one of which posed an immediate health and safety risk and resulted in a civil penalty. These medication-related deficiencies occurred in early 2024, but the most recent report from March 28, 2025, showed no deficiencies and a clean facility environment. Other minor issues, such as resident access to potentially hazardous items, were noted but did not lead to serious enforcement actions. Overall, the facility’s record shows improvement over time, with the latest inspection confirming compliance and no current concerns.
The visit was an unannounced annual inspection conducted by Licensing Program Analyst L. Xiong to evaluate the facility's compliance with licensing requirements.
Findings
The facility appeared clean with no obstructions or fire clearance issues. All common areas and resident bedrooms met required accommodations. Safety equipment such as smoke detectors, carbon monoxide detectors, and fire extinguishers were operational and up to date. Water temperature was within acceptable limits. No deficiencies were observed during the inspection.
Report Facts
Water temperature: 115Fire extinguisher service date: 2024Inspection start time: 1028Inspection end time: 144
Employees Mentioned
Name
Title
Context
Jeff Moyer
Administrator
Met with Licensing Program Analyst during inspection
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2024-07-18 alleging rough handling and inappropriate speech by facility staff towards a resident.
Findings
The investigation found the allegations to be unsubstantiated due to lack of preponderance of evidence proving the alleged violations occurred.
Complaint Details
The complaint alleged that facility staff handled a resident in a rough manner and spoke inappropriately to a resident in care. The allegations were investigated and found to be unsubstantiated.
The visit was an unannounced case management follow-up on an incident report regarding a resident not receiving as needed (PRN) medication as ordered, and failure to update the medication administration record (MAR) accordingly.
Findings
The facility failed to ensure that Resident 1 received medications as ordered by the physician, and did not update the MAR to reflect hospice agency changes. A deficiency was issued for this repeat violation, posing an immediate health and safety risk.
Complaint Details
The visit was triggered by an incident report alleging failure to administer PRN medication as ordered and failure to update the MAR accordingly. A civil penalty was assessed for a repeat violation.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Licensee did not ensure that Resident 1’s medications were received as ordered by the physician. New orders were provided but not inputted to the MAR, resulting in Resident 1 not receiving medications as ordered, posing an immediate health and safety risk.
Type A
Report Facts
Census: 100Total Capacity: 150
Employees Mentioned
Name
Title
Context
Jeff Moyer
Administrator
Met with Licensing Program Analyst during the visit and involved in plan of correction
Karen Sutherland
Health Service Director
Met with Licensing Program Analyst during the visit
Katie Brown
Licensing Program Analyst
Conducted the case management visit and authored the report
The inspection was an unannounced annual inspection conducted by Licensing Program Analysts to assess compliance with regulatory requirements.
Findings
The facility was found to be clean, odor free, and well maintained with no deficiencies issued. Safety equipment and emergency preparedness were verified, and required documentation was requested for submission.
Report Facts
Hot water temperature range: 108Hot water temperature range: 110.9Fire extinguisher last serviced: May 23, 2023Last fire drill conducted: Jan 4, 2024Non-perishable food supply: 7Perishable food supply: 2
Employees Mentioned
Name
Title
Context
Jeff Moyer
Administrator
Met with Licensing Program Analysts during inspection and received report
The visit was conducted as a follow-up on incident reports submitted to the Fresno Community Care Licensing office, specifically regarding medication administration outside physician parameters and bruising incidents.
Findings
A deficiency was issued for failure to comply with regulations when facility staff administered medication to a resident outside the parameters set by the resident's physician, posing an immediate health and safety risk. The visit included review and development of a plan of correction with the administrator.
Complaint Details
The visit was complaint-related, following up on incidents including medication administration outside physician parameters and bruising to a resident's arms. A deficiency was substantiated related to medication administration.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Facility staff administered medication to resident R1 outside of the parameters set by R1’s physician, violating section 87465 Incidental Medical and Dental Care.
Type A
Report Facts
Capacity: 150Census: 102Deficiency count: 1Plan of Correction Due Date: Due date is 02/13/2024 (date only, no numeric value extracted)
Employees Mentioned
Name
Title
Context
Jeff Moyer
Administrator
Met with Licensing Program Analyst during inspection and involved in plan of correction
Alexandria Walton
Licensing Program Analyst
Conducted the inspection and signed the report
Melinda Hoffmann
Licensing Program Manager
Named as Licensing Program Manager overseeing the inspection
The inspection visit was an unannounced Case Management - Health and Safety inspection conducted to review a Special Incident Report involving a resident's unwitnessed fall and subsequent death.
Findings
During the visit, the Licensing Program Analyst toured the facility, reviewed the resident's file, and found no citations or deficiencies.
Report Facts
Capacity: 150Census: 103
Employees Mentioned
Name
Title
Context
Jeff Moyer
Administrator
Met with Licensing Program Analyst during inspection
Katie Brown
Licensing Program Analyst
Conducted the Case Management - Health and Safety inspection
The inspection was an unannounced case management - other inspection conducted by Licensing Program Analyst Malia Thao to review the facility's compliance and amend a previous report.
Findings
No deficiencies were cited during this inspection. The Licensing Program Analyst amended a previous report (LIC809) issued on 2/21/23.
Employees Mentioned
Name
Title
Context
Jeff Moyer
Administrator
Met with Licensing Program Analyst during inspection and acknowledged receipt of the report.
Malia Thao
Licensing Program Analyst
Conducted the inspection and amended previous report.
The inspection was an unannounced annual inspection conducted to evaluate the facility's compliance with licensing requirements.
Findings
No deficiencies were cited during the inspection. Observations included residents having access to disinfectants, cleaning solutions, and a knife set, but no deficiency was issued due to resident capability to manage medications and hygiene items. The facility was advised to review resident-specific physician reports to ensure safety.
Deficiencies (1)
Description
Residents had disinfectants and cleaning solutions accessible in their apartments and one resident had a knife set on the kitchenette counter, which could pose a danger if not properly managed.
Report Facts
Residents sampled with disinfectants/cleaning solutions accessible: 10Residents sampled with disinfectants/cleaning solutions accessible: 9
Employees Mentioned
Name
Title
Context
Jeff Moyer
Administrator
Met with Licensing Program Analyst during inspection and named in report
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2022-06-06 regarding resident injuries, medication administration, staff qualifications, and care practices.
Findings
The investigation found that the allegations were either unsubstantiated or unfounded based on record reviews and interviews. The facility followed proper procedures for resident care, medication administration times were being adjusted with physician approval, staff were appropriately trained, and residents were not made to get up early.
Complaint Details
The complaint investigation addressed allegations including resident sustaining multiple injuries, improper use of a hoyer lift, medication not dispensed on time, staff not following doctor's orders, unqualified staff providing care, and residents being made to get up early. All allegations were found unsubstantiated or unfounded after review.
Report Facts
Capacity: 150Census: 89
Employees Mentioned
Name
Title
Context
Jeff Moyer
Administrator
Met with Licensing Program Analyst during complaint investigation
An unannounced complaint investigation was conducted in response to an allegation that the facility air conditioner was in disrepair.
Findings
The investigation found that although there was an issue with the air conditioner, the facility had fixed the problem and provided cooling units for the rooms. The complaint was determined to be unfounded and was dismissed.
Complaint Details
The complaint alleging the facility air conditioner was in disrepair was investigated and found to be unfounded.
Report Facts
Capacity: 150Census: 79
Employees Mentioned
Name
Title
Context
Jeff Moyer
Administrator
Facility administrator contacted during the investigation
Miguel Lopez
Executive Chef
Met with Licensing Program Analyst and assisted with the visit
The visit was an unannounced Case Management visit regarding an elopement incident that occurred on 08/04/2021.
Findings
The resident exited the facility triggering an alarm, but staff quickly located and returned the resident safely. No deficiencies were observed during the visit.
Complaint Details
The visit was triggered by a complaint related to an elopement incident. The complaint was investigated and no deficiencies were found.
Employees Mentioned
Name
Title
Context
Jeff Moyer
Administrator
Met with Licensing Program Analyst during the visit and involved in the incident discussion.
Marissa Stanley
Health Director
Met with Licensing Program Analyst during the visit and involved in the incident discussion.
Licensing Program Analyst Shawna Doucette conducted an Annual Inspection as a required 1-year unannounced visit to evaluate compliance with licensing regulations.
Findings
No deficiencies were observed during the inspection. The facility maintained proper infection control measures, adequate food supplies, and updated resident emergency contact information.
Report Facts
Capacity: 150Census: 81
Employees Mentioned
Name
Title
Context
Jeff Moyer
Administrator
Met with Licensing Program Analyst during inspection and discussed purpose of visit
Marissa Stanley
Health Director
Assisted with the inspection visit and responded to Licensing Program Analyst
Shawna Doucette
Licensing Program Analyst
Conducted the annual inspection
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