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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209442
Report Date: 08/04/2026
Date Signed: 08/04/2026 05:42:56 PM

Document Has Been Signed on 08/04/2026 05:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SGS CARE HOME IFACILITY NUMBER:
107209442
ADMINISTRATOR/
DIRECTOR:		STANFIELD, GLADYSFACILITY TYPE:
740
ADDRESS:5414 E BALCH AVETELEPHONE:
(559) 398-0953
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 6CENSUS: 6DATE:
08/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH: Imelda Balallo TIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. Administrator (AD) Gladys Stanfield was unable to attend in person but joined the inspection via phone. Facility Designee, Imelda Balallo joined LPA in person for the visit.

During this visit, LPA toured the facility inside & out. Resident rooms and common areas were clean, in good repair and contained required furnishings and lighting. LPA observed required items in bathrooms which were clean with hot water measuring 115 degrees. LPA observed hygiene items, paper products, towels, extra bedding, and linens which were available for use. The kitchen was clean, containing necessary cooking items and appliances. LPA observed required food supply, including emergency food. Medications are centrally stored in a locked cabinet in the dining area. Knives/sharps, cleaning/disinfecting supplies chemicals are inaccessible and stored away from food in the garage. Doors and passageways are unobstructed throughout the facility including outdoors. First aid kit contained required items.

LPA walked outside to find the grounds well-kept with patio and seating areas. A self-releasing gate was working properly. The fire extinguisher was serviced 5/4/26 by Jorgensen. LPA conducted resident and staff file reviews including a medication audit. Emergency Disaster & Infection Control Plans were reviewed. Fire Drills are up to date.



Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D
An exit interview was conducted, a Plan of Correction was developed with AD and a copy of this report was provided. SEE LIC809-C FOR CONTINUATION OF THIS REPORT
Shawna Doucette
Katie Brown
DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/04/2026 05:42 PM - It Cannot Be Edited


Created By: Katie Brown On 08/04/2026 at 04:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SGS CARE HOME I
FACILITY NUMBER: 107209442

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
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. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. LPA observed an exposed leg injury on R1's lower right leg. R1 is not currently under care and treatment of a clinician or Home Health. R1 has refused care by previous agencies but licensee has not sent R1 for medical evaluation and treatment.
POC Due Date: 08/04/2026
Plan of Correction
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During the inspection, R1 agreed to be evaluated by medical professionals. EMS was contacted and R1 was taken to the hospital for evaluation. DEFICIENCY CLEARED DURING VISIT.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed on a side table in the common area beside R2 a nasal spray, Prostate tablets and Tums. These medications were accessible to residents with Dementia.
POC Due Date: 08/04/2026
Plan of Correction
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During the inspection, the medications were properly secured as required.
DEFICIENCY CLEARED DURING VISIT.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Katie Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/04/2026 05:42 PM - It Cannot Be Edited


Created By: Katie Brown On 08/04/2026 at 04:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SGS CARE HOME I
FACILITY NUMBER: 107209442

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. Staff did not document PRN medication use as required - medication was documented as scheduled 3x a day on a routine MAR.
POC Due Date: 08/18/2026
Plan of Correction
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AD has agreed to provide inservice for all staff on complete documentation of PRN medication for all residents. Proof of in-service will be submitted to CCL by POC date via fax.
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review], the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. R2's Physician Report was last updated 11/18/22, R3's is dated 8/12/24 and was not updated after coming off hospice (change of condition). R2 and R3's Care Plans have not been updated since since 8/2024.
POC Due Date: 08/18/2026
Plan of Correction
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AD has agreed to conduct an audit of 6/6 resident files. A written statement will be submitted explaining that the audit is complete and that files will be complete and current within 90 days. The statement will be submitted by POC date to CCL via fax.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Katie Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/04/2026 05:42 PM - It Cannot Be Edited


Created By: Katie Brown On 08/04/2026 at 04:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SGS CARE HOME I
FACILITY NUMBER: 107209442

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(28)
(28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.

This requirement is not met as evidenced by:



Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. While observing the kitchen and refrigerators, LPA observed spoiled bagged spinich and lettuce, oranges and hot dog buns.
POC Due Date: 08/04/2026
Plan of Correction
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All spoiled food items were immediately discarded.
DEFICIENCY CLEARED DURING VISIT
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Katie Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2026


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: SGS CARE HOME I
FACILITY NUMBER: 107209442
VISIT DATE: 08/04/2026
NARRATIVE
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LPA observed the following deficiencies during today’s inspection:
-R1 has an exposed leg injury or wound requiring medical assessment
-Over the counter medications were accessible in common area to residents in care
-Staff did not document resident PRN medication use as required
-Resident files were not complete and current (Physician Reports and Care Plans)
-Spoiled produce was observed


LPA requested the following updated forms faxed to CCLD by 8/___- Infection Control Lead Certification, Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Client Roster (LIC 9020) and Proof of current Liability Coverage.
NAME OF LICENSING PROGRAM MANAGER: Shawna Doucette
NAME OF LICENSING PROGRAM ANALYST: Katie Brown
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
LIC809 (FAS) - (06/04)
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