Inspection Reports for River Bluffs Memory Care
5425 W Spruce Ave, Fresno, CA 93722, CA, 93722
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with several complaint investigations unsubstantiated or unfounded. The facility generally maintained compliance with infection control, safety, and resident care standards. However, some deficiencies were cited over time, mainly involving storage and access to hazardous items, bathroom cleanliness, medication documentation, and exceeding hospice care waiver capacity. The most recent report from August 28, 2025, cited a deficiency for lack of a physician’s order for postural supports and unsafe bed side rail use, but no severe enforcement actions or fines were listed in the available reports. There is no clear pattern of worsening or improvement, as some issues were resolved promptly while others recurred intermittently.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 33
Capacity: 36
Deficiencies: 1
Aug 28, 2025
Visit Reason
The visit was a Case Management conducted in conjunction with a complaint investigation (Control Number 24-AS-20250822151010) to address deficiencies related to postural supports in the facility.
Findings
A deficiency was cited for failure to ensure a written physician's order for postural supports (1/2 side rails) on a resident's hospital bed. The bed had 3 1/2 side rails attached, exceeding the allowed number, posing a potential health and safety risk.
Complaint Details
The visit was triggered by a complaint (Control Number 24-AS-20250822151010) and conducted as a Case Management in conjunction with the complaint investigation.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure there was a written physician's order indicating the resident's need for a postural support (1/2 side rails) for R1's hospital bed. There were 3 1/2 side rails attached to the bed, there should only be 1 per side. | Type B |
Report Facts
Census: 33
Total Capacity: 36
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the Case Management and complaint visit |
| Donna Hurley | Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Annual Inspection
Census: 34
Capacity: 36
Deficiencies: 2
Jun 4, 2025
Visit Reason
The visit was an unannounced annual inspection conducted by the Licensing Program Analyst to evaluate compliance with licensing requirements.
Findings
The facility was generally found to be clean, well-maintained, and compliant with many requirements; however, deficiencies were cited related to storage and access of potentially hazardous items and hygiene supplies, posing immediate and potential risks to residents.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Sharp knives used for cooking were found in an unlocked drawer in the kitchen due to a non-working lock, posing an immediate health and safety risk. | Type A |
| The Beauty Shop door was unlocked containing scissors and haircare supplies, and hygiene supplies were accessible under a bathroom sink in room 13, posing a potential health and safety risk to residents with documented risk if allowed access. | Type B |
Report Facts
Capacity: 36
Census: 34
Fire extinguisher service date: Jun 2, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Hurley | Administrator | Met with Licensing Program Analyst during inspection and involved in Plan of Correction |
| Katie Brown | Licensing Program Analyst | Conducted the inspection and signed the report |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 36
Deficiencies: 1
Mar 5, 2025
Visit Reason
The visit was a Case Management inspection conducted in conjunction with a complaint investigation to assess compliance with storage and access regulations.
Findings
During the visit, unsecured hazardous items including a sharp cooking knife, a bottle of bleach, and an unattended housekeeping cart with cleaning supplies were found accessible to residents. These items were immediately removed and locked, and a deficiency was cited but cleared during the visit.
Complaint Details
The visit was triggered by a complaint investigation. The deficiency cited was cleared during the visit.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure a sharp cooking knife in the kitchen, bottle of bleach in a laundry room, and an open housekeeping cart were locked and inaccessible to residents in care, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 36
Census: 33
Deficiencies cited: 1
Plan of Correction Due Date: Mar 6, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexis Martin | Wellness Director (LVN) | Met with Licensing Program Analyst during the inspection |
| Donna Hurley | Administrator | Facility Administrator unavailable at time of visit |
| Katie Brown | Licensing Program Analyst | Conducted the Case Management visit and complaint investigation |
| Sergiy Pidgirny | Licensing Program Manager / Supervisor | Supervisor and Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 36
Deficiencies: 1
Mar 5, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations including failure to maintain bathroom cleanliness, lack of care and supervision resulting in hospitalization, and failure to provide pest control resulting in resident room infestation.
Findings
The investigation substantiated the allegation that the facility failed to maintain bathroom cleanliness, citing unsanitary toilets, broken toilet seats, and improperly disposed briefs. The allegations of lack of care resulting in hospitalization and pest control failure were unsubstantiated due to insufficient evidence and no observed infestation.
Complaint Details
The complaint investigation was substantiated for failure to maintain bathroom cleanliness. The allegations of lack of care and supervision resulting in hospitalization and failure to provide pest control resulting in resident room infestation were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to maintain clean, safe, sanitary, and in good repair bathrooms; multiple resident toilets were unsanitary, two toilet seats broken, and a soiled resident brief found on the floor. | Type B |
Report Facts
Capacity: 36
Census: 33
Deficiency count: 1
Plan of Correction Due Date: Mar 19, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Alexis Martin | Wellness Director, LVN | Met with Licensing Program Analyst during the investigation and received report |
| Donna Hurley | Administrator | Facility administrator unavailable during visit but named in report |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 36
Deficiencies: 0
Sep 24, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 07/17/2024 regarding alleged failure to seek timely medical attention for a resident who ingested incorrect medication, inadequate staff training, communication issues, and insufficient staffing for resident toileting needs.
Findings
The investigation found the allegation of failure to seek timely medical attention unsubstantiated due to lack of evidence. Allegations regarding inadequate staff training and communication were substantiated as unfounded after record reviews and interviews. The allegation of insufficient staffing to meet toileting needs was also found unfounded after observations and schedule reviews. No citations were issued.
Complaint Details
The complaint involved multiple allegations: 1) Facility staff did not seek timely medical attention for a resident who ingested incorrect medication (unsubstantiated). 2) Licensee does not ensure staff are adequately trained (unfounded). 3) Facility staff are unable to communicate with residents (unfounded). 4) Licensee does not ensure facility is adequately staffed to meet resident's toileting needs (unfounded).
Report Facts
Capacity: 36
Census: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Alexis Martin | Wellness Director | Met with Licensing Program Analyst during investigation |
| Donna Hurley | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 36
Deficiencies: 0
Sep 24, 2024
Visit Reason
An unannounced complaint investigation was conducted following allegations received on 09/16/2024 regarding staff behavior and resident care at River Bluffs Memory Care Community.
Findings
The investigation found residents dressed in clean clothes with no odors, clean bedding, and staff interviews denied the allegations. Resident interviews were limited due to dementia. Record reviews showed proper care for ostomy and catheter bags. The allegations were unsubstantiated due to lack of evidence.
Complaint Details
The complaint included allegations of staff yelling at residents, racism, failure to change residents' clothing, aggressive behavior during care, and unmet resident needs. The investigation concluded these allegations were unsubstantiated.
Report Facts
Estimated Days of Completion: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Sergiy Pidgirny | Licensing Program Manager | Named in report as Licensing Program Manager |
| Alexis Martin | Facility representative who received the report | |
| Donna Hurley | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 34
Capacity: 36
Deficiencies: 2
May 15, 2024
Visit Reason
The Licensing Program Analyst arrived unannounced to conduct the Annual Inspection of the facility.
Findings
The facility was generally found to be in good repair with proper hygiene, medication storage, and safety measures. However, deficiencies were cited related to exceeding hospice care waiver capacity and incomplete medication start date records.
Deficiencies (2)
| Description |
|---|
| The facility has a Hospice Waiver for 8 residents but currently has 9 residents admitted and receiving Hospice care, exceeding the approved capacity. |
| In 2 out of 3 medication count audits, medication start dates were not accurately recorded on the centrally stored log, posing a potential health and safety risk. |
Report Facts
Hospice care capacity: 8
Hospice care residents: 9
Medication count audits: 3
Medication audits with errors: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Hurley | Administrator | Met with Licensing Program Analyst during inspection and involved in Plan of Correction |
| Alexis Martin | Wellness Director | Met with Licensing Program Analyst during inspection |
| Katie Brown | Licensing Program Analyst | Conducted the Annual Inspection and authored the report |
| Sergiy Pidgirny | Licensing Program Manager | Supervisor of the Licensing Program Analyst |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 36
Deficiencies: 0
Oct 26, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 10/24/2023 regarding staff blocking facility exits and inappropriate staff conduct towards a resident.
Findings
The investigation found the allegations unsubstantiated or unfounded based on observations, interviews, and record reviews. No citations were issued and the facility was found to have unobstructed exits and no evidence of inappropriate staff conduct or locked resident rooms.
Complaint Details
The complaint investigation was unannounced and conducted by Licensing Program Analyst Katie Brown. Allegations included staff blocking exits and speaking inappropriately to a resident, as well as concerns about fire alarms and locking a resident in their room. The allegations were found unsubstantiated or unfounded with no citations issued.
Report Facts
Capacity: 36
Census: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Donna Hurley | Administrator | Facility administrator met during investigation and named in findings |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 35
Capacity: 36
Deficiencies: 1
Jun 6, 2023
Visit Reason
The visit was an unannounced annual inspection conducted by Licensing Program Analysts to evaluate compliance with regulatory requirements at the River Bluffs Memory Care Community facility.
Findings
The inspection found the facility generally compliant with regulatory standards, including proper storage of medications, clean kitchen, and functioning safety equipment. However, a deficiency was cited for improper storage of potentially hazardous items accessible to residents.
Deficiencies (1)
| Description |
|---|
| Improper storage of disinfectants and cleaning solutions, evidenced by a razor found in the shower of room 2 and Shout laundry spray in the bathroom of room 16, posing a potential health, safety, or personal rights risk to persons in care. |
Report Facts
Capacity: 36
Census: 35
Plan of Correction Due Date: Jun 14, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Hurley | Administrator | Facility Administrator met during inspection and responsible for Plan of Correction |
| Katie Brown | Licensing Program Analyst | Conducted the inspection and signed the report |
| Miriam Flores | Licensing Program Analyst | Conducted the inspection |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 36
Deficiencies: 0
Oct 24, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by a complaint received on 07/08/2022 alleging the facility was in disrepair and that staff left a resident in soiled clothing for an extended period of time.
Findings
The investigation included a facility tour, staff interviews, and record reviews. The Department was unable to substantiate the allegations of facility disrepair and staff leaving a resident in soiled clothing. No citations were issued.
Complaint Details
The complaint was unsubstantiated. Although the allegations may have happened or be valid, there was not a preponderance of evidence to prove the alleged violations occurred.
Report Facts
Capacity: 36
Census: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Alexis Martin | Wellness Director | Met with Licensing Program Analyst during the visit |
| Donna Hurley | Administrator | Provided information regarding facility conditions |
Inspection Report
Routine
Census: 35
Capacity: 36
Deficiencies: 0
Apr 18, 2022
Visit Reason
Unannounced infection control inspection conducted as a required 1-year visit to assess compliance with infection control procedures.
Findings
The inspection found that infection control procedures were properly followed, including symptom screenings, testing, visitation requirements, quarantine/isolation procedures, staffing, PPE use, and daily infection control. No deficiencies were cited during the visit.
Report Facts
Residents vaccinated: 35
Capacity: 36
Census: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Hurley | Administrator | Met with Licensing Program Analyst during inspection. |
| Katie Brown | Licensing Program Analyst | Conducted the infection control inspection. |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on report. |
Inspection Report
Complaint Investigation
Capacity: 36
Deficiencies: 0
Apr 18, 2022
Visit Reason
The visit occurred to deliver the amended Complaint Investigation Report related to Complaint Control Number 24-AS-20211040612101.
Findings
The Licensing Program Analyst delivered the amended complaint investigation report and conducted an exit interview with the facility administrator. No specific findings or deficiencies are detailed in this report.
Complaint Details
Complaint Control Number 24-AS-20211040612101 was the basis for this visit; the report delivered was an amended complaint investigation report.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Hurley | Administrator | Met with Licensing Program Analyst during delivery of amended complaint investigation report and exit interview. |
| Katie Brown | Licensing Program Analyst | Delivered the amended complaint investigation report and conducted exit interview. |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager in the report. |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 36
Deficiencies: 0
Apr 18, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was unable to conduct a timely assessment for a resident's hospital discharge.
Findings
The investigation found conflicting information from multiple interviews and record reviews. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence proving the violation occurred.
Complaint Details
The complaint alleged the facility was unable to conduct a timely assessment for a resident's hospital discharge. The allegation was investigated and found unsubstantiated.
Report Facts
Capacity: 36
Census: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Donna Hurley | Administrator | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 36
Deficiencies: 0
Nov 2, 2021
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit triggered by allegations received on 04/06/2021 regarding resident care concerns at Compass Pointe Memory Care.
Findings
The investigation found that although the allegations regarding unreachable call lights, pressure injuries, numerous wounds, and rough handling of a resident may have occurred or be valid, there was not a preponderance of evidence to substantiate any violations. All allegations were determined to be unsubstantiated.
Complaint Details
The complaint investigation involved allegations that a resident's call light was not reachable, the resident sustained pressure injuries and numerous wounds while in care, and that staff handled the resident roughly causing injury. After interviews with the resident, family, home health personnel, and facility staff, as well as records review, the allegations were found unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 36
Census: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Donna Hurley | Administrator | Facility administrator met with Licensing Program Analyst during investigation and exit interview |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Monitoring
Census: 35
Capacity: 36
Deficiencies: 0
Sep 17, 2021
Visit Reason
The visit was an unannounced case management health and safety check conducted to observe Resident (R1) following receipt of a SOC 341 on 2021-09-08.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst met with the Administrator and Resident (R1) and conducted an exit interview.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Hurley | Administrator | Met with Licensing Program Analyst during the visit. |
| Katie Brown | Licensing Program Analyst | Conducted the health and safety visit. |
| Sergiy Pidgirny | Licensing Program Manager | Named in the report header. |
Inspection Report
Routine
Census: 35
Capacity: 36
Deficiencies: 0
May 21, 2021
Visit Reason
The inspection was an unannounced Infection Control Inspection conducted as a required one-year visit to assess compliance with infection control procedures.
Findings
The facility was found to be in compliance with infection control practices including symptom screenings, visitation policies, quarantine procedures, PPE use, and staff training. No deficiencies were cited during the inspection.
Report Facts
PPE supply: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Hurley | Administrator | Met with Licensing Program Analysts during inspection and identified as Infection Control Lead |
| Katie Brown | Licensing Program Analyst | Conducted the Covid Contact questionnaire and infection control inspection |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 36
Deficiencies: 0
May 18, 2021
Visit Reason
Unannounced complaint investigation visit conducted due to an allegation that a resident sustained a fracture while in care.
Findings
The investigation found that a resident was transferred to a hospital with a mildly displaced left femoral neck fracture, but the facility had no records of a fall and prior x-rays showed no fractures. There was insufficient evidence to prove the alleged violation, so the complaint was unsubstantiated and no deficiencies were cited.
Complaint Details
Allegation that a resident sustained a fracture while in care was investigated and found unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 36
Census: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation |
| Donna Hurley | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Capacity: 36
Deficiencies: 0
Apr 7, 2021
Visit Reason
The visit was an unannounced Health and Safety Inspection conducted by Licensing Program Analyst Katie Brown to assess the facility's compliance with health and safety regulations.
Findings
The Licensing Program Analyst toured the facility with the Administrator and removed a resident's file for copying at the CCLD office, with no deficiencies or violations explicitly stated in the report.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the Health and Safety Inspection and toured the facility. |
| Donna Hurley | Administrator | Facility Administrator who met with the Licensing Program Analyst during the inspection. |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Capacity: 36
Deficiencies: 0
Mar 16, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 08/27/2020 alleging that the facility illegally evicted a resident and that a resident eloped from the facility on multiple occasions.
Findings
The investigation found the allegations to be unfounded. It was confirmed that no eviction took place and the resident was relocated by the family. The resident did elope but not due to facility neglect or lack of supervision. The complaint was dismissed.
Complaint Details
The complaint alleged that the facility illegally evicted a resident and that a resident eloped from the facility on multiple occasions. The complaint was found to be unfounded and dismissed.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation and communicated findings. |
| Donna Hurley | Administrator | Spoke with Licensing Program Analyst regarding complaint allegations. |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 36
Deficiencies: 0
Dec 1, 2020
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2020-11-23 alleging that staff unlawfully evicted a resident while in care.
Findings
The Licensing Program Analyst contacted the facility via telephone due to COVID-19 precautions, interviewed the administrator, and reviewed the resident's file. It was confirmed that the resident was never evicted and still resides at the facility. The allegation was found to be unfounded.
Complaint Details
The complaint alleged that staff unlawfully evicted a resident while in care. The investigation found the allegation to be unfounded as the resident was never evicted.
Report Facts
Facility capacity: 36
Census: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Hurley | Administrator | Interviewed during complaint investigation |
| See Moua | Licensing Program Analyst | Conducted the complaint investigation |
Loading inspection reports...
