Inspection Reports for Summerfield of Fresno

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.

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.

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.

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.

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.

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.

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.

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

The 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.

Unannounced visit/investigation of a complaint received on 2025-04-15 regarding multiple allegations of inadequate care and staffing issues at the facility.

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.

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.

Unannounced visit/investigation of a complaint received on 2025-04-15 regarding staff not having current training.

Based on records reviewed, interviews, and observations, the allegations were unsubstantiated and no deficiencies were cited during the visit.

The complaint alleging staff do not have current training was investigated and found unsubstantiated based on the preponderance of evidence standard per Title 22.

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.

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.

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.

An unannounced case management visit was conducted on 07/12/2025 following observations made during a complaint visit on the same date.

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.

This case management visit was conducted based on observations made during a complaint visit on 07/12/2025.

An unannounced complaint investigation visit was conducted in response to an allegation that staff inappropriately restrains a resident.

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.

The complaint alleging inappropriate restraint of a resident was substantiated based on evidence collected during the unannounced visit.

The visit was an unannounced Case Management inspection conducted due to a complaint received on the date of the visit.

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.

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.

An unannounced complaint investigation visit was conducted in response to an allegation that staff were not mitigating the spread of scabies in the facility.

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.

The complaint alleged that staff were not mitigating the spread of scabies in the facility. The allegation was found to be unsubstantiated.

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.

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.

The visit was complaint-related, associated with complaint #24-AS-20240906130954. The deficiency regarding failure to obtain timely medical care was substantiated.

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.

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

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

The inspection was an unannounced annual inspection visit conducted to evaluate health and safety compliance at the facility.

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

The 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.

No deficiencies were cited during the visit. Additional records were requested for review, and an exit interview was completed with the Executive Director.

Unannounced complaint investigation visit conducted due to a complaint alleging that staff do not meet residents' diapering needs.

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 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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

The complaint 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.

An unannounced complaint investigation visit was conducted in response to allegations received on 09/06/2024 regarding medication storage, medication administration, and facility maintenance.

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.

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.

An unannounced complaint investigation visit was conducted due to an allegation that staff did not prevent an outbreak of scabies.

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

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

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.

The investigation found the allegations to be unsubstantiated or unfounded after review of records and interviews, with no citations issued.

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.

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.

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.

The visit was an unannounced annual infection control and health and safety inspection conducted by the Licensing Program Analyst.

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.

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.

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.

The complaint was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.

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.

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.

The complaint was unsubstantiated due to insufficient evidence to prove the alleged violations occurred.

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.

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.

The complaint was unsubstantiated after investigation. No deficiencies were cited.

Licensing Program Analyst arrived unannounced to conduct a required annual inspection of the facility.

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.

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.

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

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

The 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.

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.

The complaint investigation was unsubstantiated based on interviews, record reviews, and facility inspections conducted by Licensing Program Analyst David Ayers.

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.

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.

The complaint was unsubstantiated based on interviews, record reviews, and facility inspections conducted during the investigation.

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.

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.

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.

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.

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.

The complaint was unsubstantiated based on interviews, record reviews, and facility inspections. No neglect or questionable practice was found related to the allegations.

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.

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.

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.

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.

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.

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.

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.

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 was substantiated. Allegations included residents sustaining pressure injuries, failure to provide necessary medication, and failure to meet residents' hygiene needs.

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.

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.

The complaint was unsubstantiated after investigation, with no evidence supporting the allegations of outdated resident records, gangrene diagnosis, or failure to ensure physician visits.

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.

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.

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.

The visit was an unannounced Case Management inspection to verify the health and safety of residents in the facility.

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.