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Inspection visit

Complaint

SUMMERFIELD OF FRESNOLicense 1072089833 citations on this visit
3 citations recorded

Inspector’s narrative

What the inspector wrote

CONT... Allegation: Staff did not seek medical attention to resident. During visit LPA reviewed records and completed interviews. Interviews disclosed that R1 had an un-witnessed fall (date, time, details unknown). S1 notified S2 a fall occurred and hospice was contacted. Hospice records indicate R1 has an “unsteady gait” and “requires assistance as R1 is a fall risk”. EMS was not contacted after the fall occurred. Daily charting and hospice notes reviewed do not indicate R1 was assessed for this fall. Interviews indicated R1 is in pain, observed limping and not wanting to walk. Allegation: Staff do not follow resident's diet. R2's file was observed to have a dietary preference/orders form dated 5/5/25. Form indicates R2 was required to have a pureed diet. Interviews conducted disclosed R2’s food from the kitchen is pureed but other snacks eaten (ex: apples, cookies, etc.) are not. A special diet list was observed by LPA in the kitchen to include R2 as having a pureed diet. Allegation: Staff is not administering medications as prescribed. LPA reviewed MARS for R1. MARS indicates R1 did not receive their evening medications (Buspirone 5 mg and Senna/Docusate 8.5/50 mg) prescription on 7/2/25 and 7/4/25. Prescription for weight on resident noted every 1 st Monday of every month was not completed. The allegations listed above have met the preponderance of evidence standard per Title 22. The allegations are SUBSTANTIATED. Deficiencies cited on 9099D. If not corrected the deficiencies pose a direct health, safety and or personal rights risk to persons in care. A plan of correction was provided by Executive Director, Robert and reviewed with LPA. A copy of this report, deficiencies and appeal rights provided.

Citations

4 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87202(a)Type A

    Maintain fire clearance before retaining specified persons

    .87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement was not met as eivdence by: LPA observation. The licensee did not comply with the section cited above in that the Garden Kitchenette was observed with a broom jammed in the door handle, preventing the door from being accessed/used. Garden and Seaside kitchenette observed to take 25 (Garden) and 43 (Seaside) seconds to unlock the delayed egress door to exit. Perimeter gates observed to be locked with a chain and pad lock, preventing gates from being accessed. This poses an immediate health, safety and or personal rights risk to residents in care.

    Read full inspector narrative
  • 87465(c)(2)Type B

    Give PRN medication by physician order

    87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing...(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidence by: review of records. The licensee did not comply with the section cited above in that R1's MARS was reviewed and indicated R1 did not receive 2 medications (Buspirone 5 mg and Senna/Docusate 8.5/50 mg) on 7/2/25 and 7/4/25. This poses a potential health, safety and or personal rights risk to residents in care.

  • 87466Type B

    Regular observation and documentation of resident changes

    87466 Observation of the ResidentThe licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs... This requirement was not met as evidence by: LPA observation and record review. The Licnesee did not comply with the section cited above in that R1 had an unwitnessed fall (date and details unknown). Incident was not documented or reported and R1 did not receive timely medical care.

  • 87555(b)(10)Type B

    87555 General Food Service Requirements (b) The following food service requirements shall apply: (10) Where indicated, food shall be cut, chopped or ground to meet individual needs. This requirement was not met as evidence by file review and LPA observation. Records reviewed indicate R2 is on a pureed diet. Interviews conducted indicated R2 is being provided with food that is not always pureed. This poses a potential health, safety and or personal rights risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the July 12, 2025 inspection of SUMMERFIELD OF FRESNO?

This was a complaint inspection of SUMMERFIELD OF FRESNO on July 12, 2025. 3 citations were issued: 3 Type B.

Were any citations issued to SUMMERFIELD OF FRESNO on July 12, 2025?

Yes, 3 citations were issued (0 Type A, 3 Type B). The first citation was for: ".87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and count..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.