Inspection Reports for
The Terraces at San Joaquin Gardens a CCRC

The inspection found no deficiencies or citations. The facility was in compliance with all applicable regulations, including proper water temperatures, medication storage, fire safety equipment, and documentation of disaster drills.

Water test results reviewed during the visit were negative for any bacterial presence. The facility notified the Fresno County Health Department as part of cross-reporting. Photos of the water tests were provided and reviewed.

The inspection found that all areas toured, including Independent Living, Assisted Living, and Memory Care residences, were in compliance with regulations. No deficiencies or citations were issued during this visit.

The complaint alleged that a resident sustained 2 stage 4 pressure injuries, fractured pelvis, and internal bleeding due to staff neglect; that the facility did not have enough staff to meet residents' needs; and that facility staff failed to conduct appraisals to meet resident’s change of condition. The investigation concluded these allegations were unsubstantiated.

The Department found the allegations unsubstantiated after interviews and record reviews, determining that the resident's injuries were not preventable by staff and no deficiencies were issued during the inspection.

The inspection included tours of multiple lodges, checks of water temperatures, fire extinguishers, kitchen food storage, medication storage, and safety devices. No deficiencies or citations were issued at this time due to time constraints, and the inspection was not completed. A return visit will be scheduled to complete the annual inspection.

No deficiencies were cited during the visit. File reviews and interviews were completed, and the case remains under review by Community Care Licensing.

Two incidents were reviewed: one involving a vehicle accident between residents with no serious injury, and another involving a resident fall with a minor laceration. No deficiencies were observed during the visit.

The facility was observed to be clean, odor free, and maintained at a comfortable temperature. COVID-19 guidelines were in place, including visitor log-in and temperature checks. Medications, food supply, cleaning, and PPE supplies were adequate. Staff records showed good health and infection control training. No fire clearance or obstruction issues were noted.

No deficiencies were observed during the visit. The administrator reported that the resident involved in the incident remains in the Independent Living Neighborhood.

Complaint was regarding a resident's unwitnessed fall resulting in a fracture. The complaint was investigated and found to be unfounded.

The investigation found that the resident was at risk for falls and had a care plan in place. The resident sustained a fall on 2021-09-12 and was hospitalized. The fall was not due to neglect by facility staff. The complaint was found to be unfounded and dismissed.

The internal investigation regarding potential abuse witnessed by staff concluded that no abuse had taken place based on staff and resident interviews. No follow-up was required.

The visit was triggered by a complaint involving potential abuse by staff member S2 onto resident R1, witnessed by staff member S1. An internal investigation was conducted and documentation is pending submission.

The Licensing Program Analyst interviewed the Administrator about the incident and the internal investigation conducted. The Administrator agreed to submit documentation regarding the investigation by 09/21/2021. A follow-up will be conducted.

The Licensing Program Analyst interviewed the Administrator regarding an incident where staff was observed grabbing a resident's arm during care. The facility conducted an internal investigation, but it was determined that it was impossible to confirm if the bruising was caused by the staff due to the resident's cognitive impairments and history of arm movements.

No deficiencies were observed during the visit. The Administrator reported that Resident 1 was found on the bedroom floor with her head caught under the bed frame, appeared to have rolled off the bed, and has had a decline in cognitive impairment leading to a reassessment and updated care plan.

Inspection was conducted in conjunction with opening a complaint; no immediate health or safety concerns were observed.

The facility was toured and residents were observed with no immediate health or safety concerns noted. There appeared to be a sufficient supply of perishable and non-perishable food.

Complaint was regarding a resident sustaining a fall while in care. The complaint was investigated and found to be unfounded.

The investigation found that the resident had a history of falls and was provided immediate assessment and assistance by staff. The resident was sent to the hospital due to a change in condition. The facility monitored the resident with frequent safety checks and medication follow-up. The complaint was found to be unfounded and dismissed.

The Licensing Program Analyst spoke with the facility Administrator, who reported that another staff member would contact the analyst to provide further information regarding the death report.

The complaint alleged that a resident was found on the floor for an extended period of time. The allegation was unsubstantiated due to lack of preponderance of evidence to prove the violation did or did not occur.

The investigation included interviews and record reviews. It was found that the resident lived independently and wellness checks were conducted when the resident did not notify staff. On 5/16/2020, the resident was found on the bathroom floor with bruising, but it could not be determined how long the resident was on the floor. The allegation was unsubstantiated and no deficiencies were issued.