Inspection Reports for
Summerfield of Fresno

The visit was triggered by complaint #24-AS-20250728163307. The complaint investigation found deficiencies including failure to report incidents of resident elopement and safety issues with locked gates and delayed egress doors.

The inspection found multiple deficiencies including padlocks on all perimeter gates without proper fire clearance, a delayed egress door that did not open within the required time, and failure to report incidents of a resident eloping. Immediate civil penalties were assessed for some violations.

The complaint was substantiated based on evidence including interviews, documentation review, and observations. The resident was found outside the facility unsupervised on two occasions, contrary to medical assessment restrictions.

The investigation substantiated the allegation that staff failed to provide adequate supervision, resulting in a resident eloping from the facility on two occasions. Deficiencies were cited related to personnel requirements and supervision.

The visit was triggered by deficiencies observed during a complaint visit #24-AS-20251118140904 conducted on the same date.

The visit found that staff member S1 was working without fingerprint clearance and staff member S2 was working without being associated with the facility. Immediate civil penalties were assessed for both violations.

The complaint investigation was substantiated based on the preponderance of evidence standard per Title 22. The allegations included failure to meet medical care needs, control a scabies outbreak, ensure adequate feeding, maintain food supply, and provide clean linen.

Based on records reviewed, interviews, and observations, the allegations were substantiated. Deficiencies were issued related to the complaints, and a plan of correction was made and reviewed with the Regional VP of Operations.

The complaint was substantiated based on records reviewed, interviews, and observations. The licensee did not comply with notification requirements, posing a potential health, safety, and personal rights risk to residents.

The investigation substantiated the allegation that the facility did not notify residents' families of the scabies outbreak. Deficiencies were issued related to failure to comply with personal rights regulations, posing potential health and safety risks to residents.

The complaint was substantiated based on the preponderance of evidence standard per Title 22. Deficiencies were issued on complaint #24-AS-20250609132723 and if not corrected, will have a direct impact on persons in care.

Based on records reviewed, interviews, and observations, the allegations were substantiated. Deficiencies were issued related to the complaint and a plan of correction was made and reviewed with the Regional VP of Operations.

The complaint was substantiated based on the preponderance of evidence standard per Title 22. Deficiencies were issued on complaint #24-AS-20250306091730 and will have a direct impact on persons in care if not corrected.

The Licensing Program Analyst found the allegations substantiated based on records reviewed, interviews, and observations. Deficiencies were issued related to the complaint, and a plan of correction was made and reviewed.

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.

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 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.

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 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.

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.

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 investigation was substantiated. Allegations included odor, unmet incontinence needs, violation of personal rights, untimely response to representatives, frozen food served, and night staff sleeping. The plan of correction was made and reviewed during the exit interview.

The investigation substantiated all allegations based on records, interviews, and observations. Deficiencies were issued related to personnel requirements, facility maintenance, administrator qualifications, and personal rights violations, posing immediate or potential health, safety, and personal rights risks to residents.

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.

The investigation substantiated the allegations including resident wound worsening due to staff neglect, improper assistance with dental prosthetic devices, leaving residents in the same clothing for extended periods, failure to safeguard personal belongings, and lack of assistance with meals. Deficiencies were issued based on these findings.

The complaint investigation was substantiated. The allegations included staff neglect and inadequate supervision. A plan of correction was made and reviewed with the Regional VP of Operations, Dan Gormley.

The investigation substantiated the allegations based on records reviewed, interviews, and observations. Deficiencies were issued related to staff leaving residents in soiled clothing, lack of shower assistance, unclean rooms, inadequate food service, unmet wound care needs, staff sleeping on shift, and insufficient administrator presence.

The Department received 14 complaints over 6 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.

The Department received 14 complaints over 6 months alleging issues related to 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. Allegations with a preponderance of evidence were substantiated and civil penalties were issued.

The visit was triggered by observations made during a complaint investigation (#24-AS-20250714144938) conducted on 7/15/2025.

The inspection found that Resident R2, with a history of anxiety/aggression, became verbally aggressive on 7/14/2025 and did not have a recent needs and service plan/reappraisal completed within the last year as required by regulation. A deficiency was cited for this issue.

The complaint was substantiated based on evidence gathered during the unannounced visit. The allegations met the preponderance of evidence standard per Title 22. A plan of correction was provided by the Executive Director and reviewed by the Licensing Program Analyst.

The investigation substantiated the allegations that staff left a resident in a wheelchair overnight and that there was inadequate supervision to manage behavioral issues, including a resident becoming verbally aggressive. Deficiencies were cited related to insufficient staffing and failure to meet residents' personal rights and care needs.

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.

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.

This case management visit was conducted based on observations made during a complaint visit on 07/12/2025. Deficiencies cited were related to immediate health, safety, and personal rights risks to residents.

The inspection found that a broom was jammed in the Garden Kitchenette door handle preventing access, delayed egress doors took longer than allowed to unlock, and perimeter gates were locked with chains and padlocks, posing immediate health, safety, and personal rights risks to residents.

The complaint investigation was substantiated based on evidence including record reviews and interviews. Allegations involved failure to seek medical attention after a resident fall, failure to follow a resident's diet, and failure to administer medications as prescribed.

The investigation substantiated the allegations that staff failed to seek timely medical attention for a resident after a fall, did not consistently follow a resident's prescribed pureed diet, and failed to administer prescribed medications on specified dates. Deficiencies were cited posing direct 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.

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.

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

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 including observations, interviews, and documentation review.

The investigation substantiated the allegation that a resident was restrained using a soft tie without a physician's prescription, posing potential health, safety, and personal rights risks. Documentation review, observations, and interviews confirmed noncompliance with Title 22 regulations.

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.

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.

This case management visit was conducted in association with complaint #24-AS-20240906130954. The deficiency related to failure to obtain timely medical care was substantiated.

The investigation found that the facility failed to obtain medical care for resident R1 in a timely manner, resulting in R1 being placed on hospice and passing. Deficiencies were cited per Title 22.

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

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 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 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 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 complaint was substantiated based on evidence including interviews and record reviews. The resident was involved in multiple incidents of physical assault on other residents, and staff failed to prevent these incidents.

The investigation substantiated the allegation that staff failed to prevent a resident from physically assaulting others. Records showed the resident had aggressive behaviors and was involved in four altercations over two months, posing a risk to other residents.

The facility was generally clean, safe, and adequately furnished with functioning safety equipment. However, several deficiencies were noted including unlocked chemicals in a resident room, sagging mattress, torn carpet, broken cabinet handle, unclean toilet, debris on sidewalks, and other maintenance and cleanliness issues throughout the facility.

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.

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 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.

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 was substantiated based on interviews and records review. R1 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.

The investigation found that resident R1 was left in the sun on 07/22/2024 for an unknown amount of time, resulting in heat exposure and medical emergency. The allegation was substantiated and a citation was issued with an immediate civil penalty of $500.

The complaint investigation was substantiated. Allegations included lack of resident supervision, failure to assist with personal care needs, inadequate staff training, failure to safeguard residents' belongings, and hazardous items accessible to residents. Evidence included interviews, record reviews, tours, and observations.

The investigation substantiated all allegations, finding that the facility lacked night shift coverage in one unit, personal care needs were not met, staff training was incomplete for some employees, residents' personal belongings were not properly safeguarded, and hazardous items were accessible to residents. Deficiencies were cited and plans of correction were required.

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.

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.

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 investigation was triggered by allegations that the facility did not respond to changes in a resident's health and failed to communicate consistently and accurately with the resident's responsible party. The first allegation was unsubstantiated, while the latter two were substantiated.

The investigation found one allegation unsubstantiated regarding the facility's response to changes in a resident's health, and two allegations substantiated regarding inconsistent communication with the resident's responsible party. Deficiencies were cited related to failure to keep representatives regularly informed and to respond promptly to communications.

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 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 was substantiated. Allegations included medication errors, inadequate staff training, resident elopement, inadequate supervision, and improper care. The investigation confirmed multiple deficiencies including medication errors, lack of training, elopement incident, and inadequate care and supervision.

The investigation found multiple medication administration errors, inadequate staff training including improper use of Hoyer lifts, a resident eloped unnoticed posing immediate health and safety risks, inadequate supervision due to understaffing, failure to provide medication to three residents, failure to provide showers and grooming for at least six residents, and untreated wounds on a resident.

The complaint investigation was substantiated. Allegations included lack of supervision resulting in multiple resident falls, inadequate supervision, improper medication management, and unsanitary conditions. Some allegations such as failure to report incidents to responsible parties, withholding food, inadequate incontinence supplies, and withholding medication were unsubstantiated.

The investigation substantiated multiple deficiencies including lack of adequate supervision leading to resident falls, medication errors affecting three residents, and unsanitary conditions observed in common areas and resident bedrooms. Some allegations related to incident reporting, food withholding, and incontinence supplies were found unsubstantiated.

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

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 since June 2021. These findings were substantiated and posed 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 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 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.

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

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.