Inspection Reports for Summerfield of Fresno
6075 N Marks Ave, Fresno, CA 93711, United States, CA, 93711
Back to Facility ProfileInspection Report Summary
Most inspections over the past several years found no deficiencies, reflecting periods when the facility was clean, safe, and adequately staffed, including the annual inspection on January 18, 2024, which had no deficiencies. However, multiple complaint investigations since late 2024 substantiated serious issues related to care and supervision, staffing shortages, unmet personal hygiene needs, inadequate wound care, and failure to safeguard residents’ personal belongings. The facility also received civil penalties, including a $500 fine in December 2024 for leaving a resident unresponsive due to heat exposure, and enforcement actions related to hazardous items and insufficient staff training. The most recent reports from August 6, 2025, continued to cite deficiencies involving care and supervision, staff training, and case management, indicating ongoing challenges despite plans of correction. Several complaints were unsubstantiated, but the overall trend shows persistent concerns with resident care and staffing that have not fully improved.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
10.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
170% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
83% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 53
Capacity: 64
Deficiencies: 2
Aug 6, 2025
Visit Reason
An office meeting was conducted to discuss concerns identified by the Department, the operations of the facility, and the number of complaints received for Summerfield of Fresno. The visit followed multiple complaints and a prior Non-compliance meeting addressing citations related to care, supervision, hygiene, staff training, and other issues.
Findings
The Department received 14 complaints over six months alleging issues with 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. Findings for complaints were substantiated, and civil penalties were issued. The facility provided proof of corrections and plans to address the deficiencies.
Complaint Details
The Department received 14 complaints in six 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.
Deficiencies (2)
| Description |
|---|
| Care and supervision, meeting resident’s personal and hygiene needs, safeguarding resident’s personal belongings, ensuring hazardous items and materials were inaccessible, and staff training issues. |
| Case management deficiencies including Reporting Requirements, Fire Clearance with Civil Penalty, and Reappraisals. |
Report Facts
Complaints received: 14
Capacity: 64
Census: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Huntley | Administrator/Executive Director | Newly hired Executive Director/Administrator effective 8/4/25, mentioned in relation to addressing issues |
| Dan Gormley | Regional Vice President of Operations | Met with during the inspection, stated former Administrator/ED Rob and LVN Gabe were not transparent |
| Brenda White | Regional Manager | Present during the office meeting discussing concerns |
| See Moua | Licensing Program Manager | Present during the office meeting and named as Licensing Program Manager |
| Mary Garza | Licensing Program Analyst | Present during the office meeting and named as Licensing Program Analyst |
| Steve Kregel | COO/Owners | Present during the office meeting discussing concerns |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 64
Deficiencies: 4
Aug 6, 2025
Visit Reason
This was an unannounced complaint investigation visit triggered by a complaint received on 2025-03-06 regarding multiple allegations including facility odor, unmet resident incontinence needs, violation of residents' personal rights, untimely response to resident representatives, frozen food served, and night staff sleeping during shift.
Findings
The investigation substantiated all allegations based on records, interviews, and observations. Deficiencies were cited related to personnel requirements, facility maintenance, administrator qualifications, and residents' personal rights, posing immediate or potential health, safety, and personal rights risks to residents.
Complaint Details
The complaint investigation was substantiated based on evidence meeting the preponderance of evidence standard per Title 22. Allegations included odor, unmet incontinence needs, personal rights violations, untimely responses, frozen food, and sleeping staff.
Severity Breakdown
Type A: 1
Type B: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility personnel were insufficient and incompetent to meet residents' incontinence needs, served frozen food, and night staff were sleeping during shift. | Type A |
| Facility had an overwhelming odor of incontinence, residents' rooms had feces on walls, and dirty laundry piled in bathrooms. | Type B |
| Administrator did not respond timely to resident representatives and was not present at the facility an appropriate amount of time. | Type B |
| Facility staff did not prevent incidents between residents, violating personal rights. | Type B |
Report Facts
Capacity: 64
Census: 53
Deficiency count: 4
Plan of Correction Due Dates: Aug 7, 2025
Plan of Correction Due Dates: Aug 8, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Garza | Licensing Program Analyst | Conducted investigation and delivered findings |
| Dan Gormley | Regional VP of Operations | Met with Licensing Program Analyst during exit interview and developed plan of correction |
| Beronica Galindo | Administrator | Named in findings related to untimely response to resident representatives and insufficient presence at facility |
Inspection Report
Complaint Investigation
Capacity: 64
Deficiencies: 5
Aug 6, 2025
Visit Reason
This was an unannounced complaint investigation visit triggered by a complaint received on 2025-04-04 regarding multiple allegations of neglect and inadequate care at the facility.
Findings
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.
Complaint Details
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.
Deficiencies (5)
| Description |
|---|
| Resident’s wound worsened due to staff neglect |
| Staff did not properly assist resident with dental prosthetic devices |
| Staff left resident in the same clothing for extended period |
| Staff did not safeguard resident’s personal belongings |
| Staff did not assist residents with their meals |
Report Facts
Facility capacity: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Garza | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Dan Gormley | Regional VP of Operations | Met with Licensing Program Analyst and made plan of correction |
| Beronica Galindo | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 64
Deficiencies: 7
Aug 6, 2025
Visit Reason
Unannounced visit/investigation of a complaint received on 2025-04-15 regarding multiple allegations of inadequate care and staffing issues at the facility.
Findings
The investigation substantiated the allegations including residents left in soiled clothing, lack of shower assistance, unclean rooms, inadequate food service, unmet wound care needs, staff sleeping on shift, and insufficient administrator presence. Deficiencies were issued and a plan of correction was made.
Complaint Details
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.
Deficiencies (7)
| Description |
|---|
| Staff left residents in soiled clothing for an extended period of time |
| Staff did not provide shower assistance to residents in care |
| Staff did not clean resident's room |
| Staff did not provide adequate food service to residents in care |
| Staff did not ensure resident's wound care needs were met |
| Staff sleep while on shift |
| Administrator is not present at the facility an appropriate amount of time |
Report Facts
Capacity: 64
Census: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Garza | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Dan Gormley | Regional VP of Operations | Met with Licensing Program Analyst and received findings; involved in plan of correction |
| Robert Huntley | Administrator | Named in allegations regarding insufficient presence at the facility |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 64
Deficiencies: 0
Aug 6, 2025
Visit Reason
Unannounced visit/investigation of a complaint received on 2025-04-15 regarding staff not having current training.
Findings
Based on records reviewed, interviews, and observations, the allegations were unsubstantiated and no deficiencies were cited during the visit.
Complaint Details
The complaint alleging staff do not have current training was investigated and found unsubstantiated based on the preponderance of evidence standard per Title 22.
Report Facts
Capacity: 64
Census: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Garza | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Dan Gormley | Regional VP of Operations | Met with Licensing Program Analyst during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 64
Deficiencies: 1
Jul 15, 2025
Visit Reason
The case management visit was conducted due to observations made during a subsequent complaint visit on 7/15/2025 regarding resident R2's care and documentation.
Findings
The inspection found that resident R2, who has a history of anxiety and aggression, became verbally aggressive with residents and staff on 7/14/2025. The facility failed to complete a recent needs and service plan/reappraisal for R2 within the last year as required by regulation, resulting in a cited deficiency.
Complaint Details
The visit was triggered by a complaint investigation (#24-AS-20250714144938) conducted on 7/15/2025. The complaint involved concerns about resident R2's behavior and care documentation. The deficiency was substantiated based on file review and interviews.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to update the pre-admission appraisal (reappraisal) for resident R2 within the last year, despite R2's history of anxiety/aggression and recent verbal aggression incidents. | Type B |
Report Facts
Residents on hospice: 5
Deficiency count: 1
Plan of Correction due date: Aug 1, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Huntley | Executive Director | Met with Licensing Program Analyst during inspection and developed plan of correction |
| Mary Garza | Licensing Program Analyst | Conducted the unannounced case management visit and inspection |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 64
Deficiencies: 1
Jul 12, 2025
Visit Reason
An unannounced case management visit was conducted on 07/12/2025 following observations made during a complaint visit on the same date.
Findings
The inspection found that a broom was jammed into the Garden Kitchenette door handle preventing access, delayed egress doors took excessive time to unlock, and perimeter gates were locked with chains and padlocks, posing immediate health, safety, and personal rights risks to residents.
Complaint Details
This case management visit was conducted based on observations made during a complaint visit on 07/12/2025.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Garden Kitchenette door handle was blocked by a broom preventing access; delayed egress doors took 25 and 43 seconds to unlock; perimeter gates locked with chain and padlock preventing access. | Type A |
Report Facts
Time to unlock delayed egress door: 25
Time to unlock delayed egress door: 43
Capacity: 64
Census: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Huntley | Executive Director | Met with Licensing Program Analyst during inspection and provided plan of correction |
| Krystle Rodriguez | Senior Memory Care Director | Met with Licensing Program Analyst and explained reason for visit |
| Mary Garza | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 64
Deficiencies: 1
May 19, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff inappropriately restrains a resident.
Findings
The investigation substantiated the allegation that a resident was restrained using a soft tie without a physician's prescription, posing potential health and safety risks. Documentation review, observations, and interviews confirmed noncompliance with regulatory requirements.
Complaint Details
The complaint alleging inappropriate restraint of a resident was substantiated based on evidence collected during the unannounced visit.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Use of soft ties on resident(s) without a physician's prescription, violating postural support regulations and posing potential health, safety, and personal rights risks. | Type B |
Report Facts
Capacity: 64
Census: 49
Deficiency Plan of Correction Due Date: May 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Garza | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Robert Huntley | Executive Director | Facility administrator involved in exit interview |
| Gabriel Facio | Licensed Vocational Nurse | Staff member involved in exit interview |
| Bryant Ward | Business Office Manager | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 64
Deficiencies: 1
Apr 18, 2025
Visit Reason
The visit was an unannounced Case Management inspection conducted due to a complaint received on the date of the visit.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit written reports to the licensing agency within seven days of incidents involving residents R1, R2, and R3 as required by Title 22 Section 87211 Reporting Requirements. | Type B |
Report Facts
Falls: 4
Capacity: 64
Census: 40
Plan of Correction Due Date: Due date for correction is 05/02/2025.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Huntley | Executive Director | Met with Licensing Program Analyst during inspection and mentioned in relation to findings. |
| Mary Garza | Licensing Program Analyst | Conducted the inspection and authored the report. |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 64
Deficiencies: 0
Apr 14, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff were not mitigating the spread of scabies in the facility.
Findings
The investigation found that although there were residents receiving treatment for rashes, there was no evidence that treatment was being provided for scabies. The allegation was determined to be unsubstantiated as it did not meet the preponderance of evidence standard.
Complaint Details
The complaint alleged that staff were not mitigating the spread of scabies in the facility. The allegation was found to be unsubstantiated.
Report Facts
Residents receiving hospice services: 9
Residents receiving treatment for rashes: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Garza | Licensing Program Analyst | Conducted the complaint investigation visit |
| Robert Huntly | Executive Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 64
Deficiencies: 1
Feb 12, 2025
Visit Reason
A Case Management visit was conducted during the NCC meeting associated with complaint #24-AS-20240906130954 to investigate concerns regarding timely medical care for a resident.
Findings
The investigation found that the facility did not obtain medical care for resident R1 in a timely manner, resulting in the resident being placed on hospice and passing. Deficiencies were cited under Title 22.
Complaint Details
The visit was complaint-related, associated with complaint #24-AS-20240906130954. The deficiency regarding failure to obtain timely medical care was substantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not obtain medical care for R1 in a timely manner, violating personnel requirements related to recognizing early signs of illness and the need for professional help. | Type B |
Report Facts
Capacity: 64
Census: 39
Plan of Correction Due Date: Feb 21, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Cormley | Regional VP of Operations | Present at the inspection and exit interview |
| Robert Huntley | Executive Director | Present at the inspection and exit interview |
| Brenda White | Regional Manager | Present at the inspection |
| See Moua | Licensing Program Manager | Conducted inspection and signed report |
| Mary Garza | Licensing Program Analyst | Conducted inspection and signed report |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 64
Deficiencies: 1
Jan 7, 2025
Visit Reason
This was an unannounced complaint investigation visit conducted due to a complaint received on 2024-10-28 alleging that staff did not prevent a resident from physically assaulting other residents in care.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to comply with CCR 87468.2(a)(4) regarding providing care, supervision, and services sufficient to meet residents' needs, resulting in resident R1's involvement in 4 altercations over 2 months. | Type B |
Report Facts
Number of incidents: 4
Facility capacity: 64
Census: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Garza | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Beronica Galindo | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview |
Inspection Report
Annual Inspection
Census: 40
Capacity: 64
Deficiencies: 13
Jan 7, 2025
Visit Reason
The inspection was an unannounced annual inspection visit conducted to evaluate health and safety compliance at the facility.
Findings
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.
Deficiencies (13)
| Description |
|---|
| Chemicals observed in room #210 unlocked and accessible to resident in care. |
| Room #407 observed with sagging mattress in need of replacement. |
| Carpet in Apple kitchenette torn at transition in need of repair. |
| Apple kitchenette cabinet handle broken and in need of repair. |
| Room #310 toilet in need of cleaning. |
| Sidewalk in courtyard in need of debris removal. |
| Hand railing in Garden wing in need of cleaning. |
| Refrigerator/freezer in Garden wing in need of cleaning/repair. |
| Spider webs observed throughout the facility in need of removal. |
| Touch up paint needed in hallways in Garden wing. |
| Seaside kitchenette flooring sticky and in need of cleaning. |
| Wall in room #428 in need of patching/touch up. |
| Personal rights, additional personal right, non-discrimination and complaint information not posted. |
Report Facts
Residents on hospice: 10
Deficiencies cited: 13
Plan of Correction Due Date: Jan 17, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beronica Galindo | Executive Director | Met with Licensing Program Analyst during inspection and named in plan of correction statements |
| Mary Garza | Licensing Program Analyst | Conducted the inspection and signed the report |
| See Moua | Licensing Program Manager | Named as supervisor and licensing program manager |
Inspection Report
Census: 41
Capacity: 64
Deficiencies: 0
Dec 31, 2024
Visit Reason
The visit was an unannounced case management visit conducted to return a resident file that had been removed for review and copying related to a previous complaint.
Findings
No deficiencies were cited during the visit. Additional records were requested for review, and an exit interview was completed with the Executive Director.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beronica Galindo | Executive Director | Met with Licensing Program Analyst during the visit and participated in exit interview. |
| Mary Garza | Licensing Program Analyst | Conducted the unannounced case management visit. |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 64
Deficiencies: 0
Dec 23, 2024
Visit Reason
Unannounced complaint investigation visit conducted due to a complaint alleging that staff do not meet residents' diapering needs.
Findings
The investigation found that personal care needs including incontinence, grooming, and bathing were not being met, based on records, observations, tours, and interviews. The allegation was substantiated but no deficiencies were cited during this visit.
Complaint Details
Complaint was substantiated based on the preponderance of evidence standard per Title 22. The allegation involved staff not meeting residents' diapering needs. Findings were previously delivered during a complaint visit on 2024-12-20.
Report Facts
Census: 41
Total Capacity: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beronica Galindo | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview. |
| Mary Garza | Licensing Program Analyst | Conducted the complaint investigation visit. |
| See Moua | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 64
Deficiencies: 0
Dec 23, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not ensure residents were adequately fed, did not ensure residents received fluids, and that a resident's toilet was in disrepair.
Findings
The investigation found that residents had an adequate food and fluid supply, repairs were requested and completed timely, and the facility was observed to be in good repair. The allegations were found to be unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint was unsubstantiated based on interviews with residents, family members, staff, and administration, as well as observations and documentation review. The preponderance of evidence standard was not met per Title 22.
Report Facts
Capacity: 64
Census: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beronica Galindo | Executive Director | Met with Licensing Program Analyst during the complaint investigation and exit interview |
| Mary Garza | Licensing Program Analyst | Conducted the complaint investigation visit |
| See Moua | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 41
Capacity: 64
Deficiencies: 0
Dec 23, 2024
Visit Reason
The visit was an unannounced case management visit conducted to obtain a resident's file and complete a health and safety check on residents in care.
Findings
No deficiencies were issued during the visit. Residents were observed in common areas and rooms, and the file requested was removed for review and will be returned in 3 business days.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beronica Galindo | Executive Director | Met with Licensing Program Analyst during the visit and participated in the exit interview. |
| Mary Garza | Licensing Program Analyst | Conducted the unannounced case management visit and health and safety check. |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 64
Deficiencies: 1
Dec 20, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 07/24/2024 regarding lack of care and supervision resulting in a resident being found unresponsive in the sun.
Findings
The investigation found that resident R1 was left in the sun on 7/22/2024 for an unknown amount of time, resulting in tachycardia, respiratory distress, and heat exposure diagnosis. Staff failed to routinely check on R1, leading to the substantiated allegation of neglect and an immediate civil penalty of $500 was assessed.
Complaint Details
The complaint was substantiated based on interviews and record review. The resident was found unresponsive due to heat exposure after being left in the sun. An immediate civil penalty of $500 was assessed with additional penalties pending review.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personnel Requirements – Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as R1 was left in the sun resulting in unresponsiveness and medical attention. | Type A |
Report Facts
Civil penalty amount: 500
Capacity: 64
Census: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beronica Galindo | Executive Director | Met with Licensing Program Analyst during the investigation and named in findings related to supervision failure. |
| Mary Garza | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report. |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 64
Deficiencies: 5
Dec 20, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 2024-09-06 regarding resident supervision, personal care assistance, staff training, safeguarding of personal belongings, and hazardous item accessibility.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility did not have coverage during the night shift in 1 of 4 units, posing a potential health, safety, and personal rights risk to residents. | Type B |
| Personal care needs including incontinence, grooming, and bathing were not being met, posing a potential health, safety, and personal rights risk. | Type B |
| Staff did not complete required training prior to being placed on the schedule without supervision for the night shift, posing a potential health, safety, and personal rights risk. | Type B |
| Incontinent supplies were not properly accounted for and were missing; storage room lacked residents' supplies, posing a health, safety, and personal rights risk. | Type B |
| Items posing danger to residents (sharps and chemicals) were found unlocked and accessible in various areas of the facility. | Type B |
Report Facts
Capacity: 64
Census: 41
Deficiencies cited: 5
Plan of Correction Due Date: Jan 3, 2025
Number of staff not properly trained: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beronica Galindo | Executive Director | Met with Licensing Program Analyst during investigation and named in findings related to facility supervision and corrective actions |
| Mary Garza | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| See Moua | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 64
Deficiencies: 0
Dec 20, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 09/06/2024 regarding medication storage, medication administration, and facility maintenance.
Findings
The investigation found that medication carts were locked and inaccessible, medications were administered as prescribed, and the facility was maintained in good repair. The allegations were found to be unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint was unsubstantiated based on the preponderance of evidence standard per Title 22. Allegations included improper medication storage, failure to ensure medications were taken as prescribed, and poor facility maintenance.
Report Facts
Capacity: 64
Census: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beronica Galindo | Executive Director | Met with Licensing Program Analyst during complaint investigation and exit interview |
| Mary Garza | Licensing Program Analyst | Conducted the complaint investigation visit |
| See Moua | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 64
Deficiencies: 1
Nov 14, 2024
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that staff did not prevent an outbreak of scabies.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to meet infection control requirements related to enhanced environmental cleaning and disinfection during a contagious disease outbreak in one wing of the facility. | Type B |
Report Facts
Capacity: 64
Census: 40
Plan of Correction Due Date: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beronica Galindo | Executive Director | Met during the inspection and named in the report |
| Mary Garza | Licensing Program Analyst | Conducted the complaint investigation |
| Michelle Reyburn | Business Office Manager | Met the Licensing Program Analyst at the facility during the visit |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 64
Deficiencies: 0
Mar 6, 2024
Visit Reason
Unannounced complaint investigation visit conducted due to a complaint received on 2023-08-29 regarding questionable death and other allegations at Summerfield of Fresno facility.
Findings
The investigation found the allegations to be unsubstantiated or unfounded after review of records and interviews, with no citations issued.
Complaint Details
Complaint involved allegations including questionable death, staff denying authorized representative entry, failure to disclose information, unauthorized transport of a resident, overcharging for services, and withholding resident's ashes. The allegations were found to be unsubstantiated or unfounded.
Report Facts
Capacity: 64
Census: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kamaldeep Kaur | Evaluator | Conducted the complaint investigation |
| Michele Reyburn | Business Office Manager | Met with during the investigation |
| Beronica Galindo | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 45
Capacity: 64
Deficiencies: 0
Jan 18, 2024
Visit Reason
The visit was an unannounced annual inspection conducted by the Licensing Program Analyst to perform a health and safety check and evaluate compliance with licensing requirements.
Findings
The facility was found to be clean, odor-free, and adequately furnished with functioning smoke and carbon monoxide detectors. Water temperatures were within acceptable ranges, and medications were properly secured. No deficiencies were cited during the inspection.
Report Facts
Residents on hospice: 11
Water temperature range: 110.3 to 119.2
Fire extinguisher last serviced: Sep 25, 2023
Last fire drill date: Dec 26, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beronica Galindo | Executive Director | Met Licensing Program Analyst during inspection and participated in exit interview |
| Mary Garza | Licensing Program Analyst | Conducted the annual inspection visit |
Inspection Report
Annual Inspection
Census: 29
Capacity: 64
Deficiencies: 0
Feb 9, 2023
Visit Reason
The visit was an unannounced annual infection control and health and safety inspection conducted by the Licensing Program Analyst.
Findings
No deficiencies were cited during the visit. Required postings were observed except for hand washing postings at hand washing stations. Fire extinguisher was last serviced on 9/22/22. Updated forms were requested to be submitted by 2/16/23.
Report Facts
Capacity: 64
Census: 29
Fire extinguisher service date: Sep 22, 2022
Forms update deadline: Feb 16, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beronica Galindo | Executive Director | Met with Licensing Program Analyst during inspection and exit interview |
| Mary Garza | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 64
Deficiencies: 0
Jan 20, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-08-26 alleging that staff did not assist residents with incontinence care, grooming, hydration, reporting changes in condition, and obtaining medical care.
Findings
The Licensing Program Analyst conducted interviews and toured the facility but found insufficient evidence to substantiate the allegations. Therefore, the complaint was determined to be unsubstantiated.
Complaint Details
The complaint was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Beronica Galindo | Executive Director | Met with the Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 64
Deficiencies: 0
Jan 20, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2022-09-12 alleging that staff failed to provide a safe and comfortable environment for residents.
Findings
The Licensing Program Analyst toured the facility and conducted interviews. Based on the investigation, there was insufficient evidence to substantiate the allegation, and the complaint was determined to be unsubstantiated.
Complaint Details
The complaint was unsubstantiated due to insufficient evidence to prove the alleged violations occurred.
Report Facts
Facility capacity: 64
Census: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Beronica Galindo | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 64
Deficiencies: 0
Mar 8, 2022
Visit Reason
This was an unannounced complaint investigation visit triggered by a complaint received on 2021-12-20 alleging that the facility was not allowing residents to return after hospitalization and did not have sufficient staff to meet residents' needs.
Findings
The investigation found that a resident was transferred to another facility due to unsafe transfer and unmet needs. The facility had hired and trained new staff and was operating below half capacity. The allegations were unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint was unsubstantiated after investigation. No deficiencies were cited.
Report Facts
Facility capacity: 64
Resident census: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Ayers | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Beronica Galindo | Executive Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Annual Inspection
Census: 28
Capacity: 64
Deficiencies: 0
Dec 9, 2021
Visit Reason
Licensing Program Analyst arrived unannounced to conduct a required annual inspection of the facility.
Findings
The facility was found to be in good condition with no deficiencies cited. All areas were clean, safe, and well maintained, with adequate supplies and proper infection control practices observed.
Report Facts
Capacity: 64
Census: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beronica Galindo | Business Office Manager | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 64
Deficiencies: 2
Dec 2, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-11-04 regarding the facility's response to changes in a resident's health and communication with the resident's responsible party.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to have representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. | Type B |
| Failure to have communications to the licensee from their representatives answered promptly and appropriately. | Type B |
Report Facts
Capacity: 64
Census: 29
Deficiencies cited: 2
Plan of Correction Due Date: Dec 16, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Ayers | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Andy Xiong | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Beronica Galindo | Business Office Manager | Met with Licensing Program Analyst during investigation |
| Linda Houlihan | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 64
Deficiencies: 0
Dec 2, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 10/08/2021 regarding staffing shortages, failure to care for residents' wounds, and unqualified staff administering medication.
Findings
The investigation found that staffing had been increased with temporary staff and the facility had enough staff to meet residents' needs. Residents with wounds were seen weekly by a physician and cared for routinely. No unqualified staff were administering medication. All allegations were unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on interviews, record reviews, and facility inspections conducted by Licensing Program Analyst David Ayers.
Report Facts
Capacity: 64
Census: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Ayers | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Beronica Galindo | Business Office Manager | Met with Licensing Program Analyst during the investigation |
| Jennifer Fowler | Administrator | Facility administrator named in the report header |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 64
Deficiencies: 0
Dec 2, 2021
Visit Reason
Unannounced visit/investigation of a complaint received on 10/19/2021 regarding allegations that staff do not ensure residents are fed and residents' diapers are not being changed.
Findings
The investigation found that the facility has appropriate systems in place to ensure residents are fed and that residents with diapers are regularly checked and changed. The allegations were determined to be unsubstantiated.
Complaint Details
The complaint was unsubstantiated based on interviews, record reviews, and facility inspections conducted during the investigation.
Report Facts
Capacity: 64
Census: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Ayers | Licensing Program Analyst | Conducted the complaint investigation |
| Beronica Galindo | Business Office Manager | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 64
Deficiencies: 0
Dec 2, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that the facility was not following Covid-19 safety protocols and that untrained staff were providing care to residents.
Findings
The investigation found that the facility was following proper COVID-19 safety protocols, including isolation of positive or exposed residents and adequate PPE usage. Staffing had been increased with properly trained new staff. The allegations were unsubstantiated.
Complaint Details
The complaint was unsubstantiated after investigation. Allegations included failure to follow Covid-19 safety protocols and untrained staff providing care, both of which were found to be untrue.
Report Facts
Capacity: 64
Census: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Ayers | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Beronica Galindo | Business Office Manager | Met with Licensing Program Analyst during the investigation |
| Jennifer Fowler | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 64
Deficiencies: 0
Sep 20, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-06-11 regarding allegations that facility staff did not seek timely medical care for a resident and that a resident sustained a pressure injury while in care.
Findings
The investigation found that facility staff did seek timely medical care for the resident in accordance with the hospice care plan. The hospice team did not report neglect or questionable practice. The resident's pressure injury was being properly treated. The allegations were unsubstantiated and no deficiencies were observed.
Complaint Details
The complaint was unsubstantiated based on interviews, record reviews, and facility inspections. No neglect or questionable practice was found related to the allegations.
Report Facts
Capacity: 64
Census: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Fowler | Executive Director | Met with Licensing Program Analyst during complaint investigation |
| David Ayers | Licensing Program Analyst | Conducted the complaint investigation |
| Andy Xiong | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 64
Deficiencies: 3
Sep 20, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations including improper medication administration, inadequate staff training, resident elopement, insufficient supervision, and inadequate resident care.
Findings
The investigation found multiple medication administration errors, inadequate staff training especially on Hoyer lift operation, a resident elopement incident due to lack of supervision, failure to provide proper medication to three residents, and failure to provide showers and grooming to at least six residents. These deficiencies posed immediate or potential health and safety risks.
Complaint Details
The complaint was substantiated. Allegations included staff not giving medications correctly, inadequate staff training, resident elopement, inadequate supervision, and improper resident care. The investigation confirmed these issues.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility personnel were insufficient in numbers and not competent to meet resident needs, evidenced by failure to supervise a resident who eloped. | Type A |
| Facility failed to provide medication for 3 residents according to physician's directions. | Type A |
| Facility failed to provide showers and grooming for at least 6 residents. | Type B |
Report Facts
Residents not supervised: 1
Residents without medication: 3
Residents without showers and grooming: 6
Immediate civil penalty: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Fowler | Executive Director | Met with Licensing Program Analyst during investigation and agreed to submit Plan of Correction. |
| David Ayers | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Andy Xiong | Licensing Program Manager | Oversaw the complaint investigation and signed the report. |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 64
Deficiencies: 3
Sep 20, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations including lack of supervision resulting in multiple resident falls, inadequate supervision, improper medication management, and unsanitary conditions.
Findings
The investigation substantiated multiple deficiencies including preventable resident falls due to lack of supervision, medication errors affecting three residents, and unsanitary facility conditions such as dust, debris, and blood in resident areas. Some allegations related to incident reporting, food withholding, incontinence care, and medication withholding were found unsubstantiated.
Complaint Details
The complaint investigation was substantiated. Allegations included lack of supervision causing multiple falls, medication mismanagement, and unsanitary conditions. Some allegations such as failure to report incidents to responsible parties, withholding food, inadequate incontinence care, and withholding medication were unsubstantiated.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to provide medication for 3 residents, posing an immediate Health & Safety risk. | Type A |
| Facility personnel were insufficient in numbers and competence to meet resident needs. | Type A |
| Facility failed to keep the common areas and at least one bedroom clean and sanitary, posing potential Health & Safety risk. | Type B |
Report Facts
Residents affected by medication errors: 3
Facility capacity: 64
Resident census: 37
Plan of Correction due date: Oct 4, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Fowler | Executive Director | Met with Licensing Program Analyst during inspection and agreed to submit Plan of Correction |
| David Ayers | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Andy Xiong | Licensing Program Manager | Oversaw complaint investigation report |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 64
Deficiencies: 2
Sep 20, 2021
Visit Reason
Unannounced complaint investigation visit conducted due to complaints received on 07/09/2021 regarding pressure injuries, medication administration failures, and hygiene neglect at the facility.
Findings
The investigation found multiple medication administration errors for three residents, failure to provide scheduled showers and hygiene care for residents due to insufficient staffing, and multiple residents sustaining pressure injuries due to inadequate care and turning in beds.
Complaint Details
Complaint was substantiated. Allegations included residents sustaining pressure injuries, failure to provide necessary medication, and failure to meet residents' hygiene needs.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide medication for 3 residents as ordered by physician, posing immediate Health & Safety risk. | Type A |
| Failure to provide showers and grooming for at least 6 residents, posing potential Health & Safety risk. | Type B |
Report Facts
Residents with medication errors: 3
Residents missing showers: 6
Facility capacity: 64
Resident census: 37
Plan of Correction due date: Oct 4, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Fowler | Executive Director | Met with Licensing Program Analyst during investigation and agreed to submit Plan of Correction. |
| David Ayers | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Andy Xiong | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 64
Deficiencies: 0
Sep 20, 2021
Visit Reason
Unannounced visit/investigation of a complaint received on 07/20/2021 regarding resident records not being updated, a resident having gangrene, and staff not ensuring a resident was seen by a physician.
Findings
The investigation found that resident records were updated and met regulatory requirements. Resident 1 was receiving wound care for an unstageable pressure injury and was not diagnosed with gangrene. The allegations were unsubstantiated.
Complaint Details
The complaint was unsubstantiated after investigation, with no evidence supporting the allegations of outdated resident records, gangrene diagnosis, or failure to ensure physician visits.
Report Facts
Capacity: 64
Census: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Fowler | Executive Director | Met with Licensing Program Analyst during complaint investigation |
| David Ayers | Licensing Program Analyst | Conducted the complaint investigation |
| Andy Xiong | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 64
Deficiencies: 0
Jul 20, 2021
Visit Reason
Unannounced investigation of a complaint received on 03/15/2021 regarding allegations of inadequate record keeping and staff interfering with a resident's medical care.
Findings
Based on interviews with staff and the responsible party, and review of records including incident reports, facility procedures, and hospice care plan, the allegations were found to be unsubstantiated. No deficiencies were observed during the investigation.
Complaint Details
The complaint was unsubstantiated after investigation. No deficiencies were found related to the allegations of inadequate record keeping and staff interference with resident medical care.
Report Facts
Facility capacity: 64
Census: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Fowler | Administrator | Met with Licensing Program Analyst during the investigation |
| David Ayers | Licensing Program Analyst | Conducted the complaint investigation |
| Andy Xiong | Licensing Program Manager | Named in report header |
Inspection Report
Census: 46
Capacity: 64
Deficiencies: 0
Jul 12, 2021
Visit Reason
The visit was an unannounced Case Management inspection to verify the health and safety of residents in the facility.
Findings
The Licensing Program Analyst toured the facility, interviewed residents, observed lunch service, and verified supplies, staffing, and record-keeping. No deficiencies were cited during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Fowler | Executive Director | Met with Licensing Program Analyst during inspection. |
| David Ayers | Licensing Program Analyst | Conducted the Case Management inspection. |
| Andy Xiong | Licensing Program Manager | Named in report header. |
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