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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208983
Report Date: 07/12/2025
Date Signed: 07/13/2025 09:08:52 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/09/2025 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20250709100532
FACILITY NAME:SUMMERFIELD OF FRESNOFACILITY NUMBER:
107208983
ADMINISTRATOR:HUNTLEY, ROBERTFACILITY TYPE:
740
ADDRESS:6075 N. MARKSTELEPHONE:
(559) 446-6226
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:64CENSUS: DATE:
07/12/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Senior Memory Care Director, Krystle RodriguezTIME COMPLETED:
07:00 PM
ALLEGATION(S):
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Staff did not seek medical attention to resident.
Staff do not follow resident's diet.
Staff is not administering medications as prescribed.
INVESTIGATION FINDINGS:
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On 7/12/25 Licensing Program Analyst (LPA) M. Garza completed an unannounced initial complaint visit. LPA met with Senior Memory Care Director, Krystle Rodriguez, explained reason for visit and was permitted entry into the facility. Executive Director, Robert Huntley was contacted and arrived some time later. LPA completed a tour of the facility inside and out. A health and safety check on residents in care was completed. Residents observed in common areas and in their rooms.

During visit LPA requested and reviewed documentation (physicians reports, central stored medication logs, hospice care plans, hospice notes, dietary orders, staff scheduled for 6/2025 and 7/2025, staff roster, daily charting notes, resident roster, training records, face sheets, weight records, discharge notes) and completed interviews.

CONT...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 24-AS-20250709100532
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: SUMMERFIELD OF FRESNO
FACILITY NUMBER: 107208983
VISIT DATE: 07/12/2025
NARRATIVE
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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 1st 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.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20250709100532
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SUMMERFIELD OF FRESNO
FACILITY NUMBER: 107208983
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/25/2025
Section Cited
CCR
87466
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87466 Observation of the Resident
The 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...
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ED to contact Hospice and/or send R1 to ER for assessment. For any future falls ED/LVN will assess and send out if needed. In-service will be completed with medical technicians and all care staff for unwitnessed falls/incidents. In-service sign in sheets and training material will be provided to CCL by POC date as proof of correction.
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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.
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Type B
07/12/2025
Section Cited
CCR
87555(b)(10)
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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.
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ED stated all staff will be provided with notification of special diets. Kitchen will be instructed to supply snacks to match diet needs. In-service will be completed with all staff. In-service sign in sheets and training material will be sent to CCL by POC date as proof of correction.
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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.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20250709100532
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SUMMERFIELD OF FRESNO
FACILITY NUMBER: 107208983
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/25/2025
Section Cited
CCR
87465(c)(2)
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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.
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ED stated medication training will be completed with all medical technicians. In-service sign in sheets and training material will be sent to CCL by POC date as proof of correction.
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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.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4