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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209256
Report Date: 01/31/2026
Date Signed: 01/31/2026 04:54:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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
12/26/2025 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20251226163231
FACILITY NAME:VERNON GARDENS RESIDENTIAL CARE CENTERFACILITY NUMBER:
157209256
ADMINISTRATOR:CUDAL, NANCYFACILITY TYPE:
735
ADDRESS:2603 MOUNT VERNON AVENUETELEPHONE:
(661) 374-8969
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY:54CENSUS: 46DATE:
01/31/2026
UNANNOUNCEDTIME BEGAN:
03:24 PM
MET WITH:Administrator Nancy CudalTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff does not ensure resident is free of lice.
Staff are mismanaging resident's medications.
Staff does not ensure resident's room is clean and sanitized.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Shawna Doucette and Sarah Hurt arrived at the facility unannounced to conduct a complaint investigation. LPA was granted entry by staff. Staff contacted the Administrator who responded to assist with the visit.

LPA interviewed R1and staff. LPA's reviewed R1's file and obtained copies.

Based on interviews and records review, R1 was believed to have lice, however facility staff did not seek medical attention and provide R1 assistance to get rid of the lice. On 1/5/26, LPA interviewed Administrator who confirmed R1 was believed to have lice and facility did not seek medical attention. On 1/5/26 after LPA conducted the intial visit facility staff sought medical attention for R1 confirming R1's condition.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2026
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 6
Control Number 24-AS-20251226163231
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: VERNON GARDENS RESIDENTIAL CARE CENTER
FACILITY NUMBER: 157209256
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/01/2026
Section Cited
CCR
80075(a)
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80075 Health Related Services (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
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Licensee agrees put a plan in writing regarding the understanding of this regulation and how it will be met by POC due date 02/01/26.
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This requirement was not met as evidenced by: Licensee did not assist R1 with medical care when R1 was noticed to have lice, which poses an immediate health, safety and or personal rights risk to residents in care.
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Type A
02/01/2026
Section Cited
CCR
80075(b)
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80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by: Licensee did not ensure R1 received
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Licensee agrees to conduct a medication training. Licensee conducted a training and will submit proof of training by POC due date 2/1/26
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his prescribed medication from 11/10/25 to 11/24/25 which poses an immediate 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: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 24-AS-20251226163231
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: VERNON GARDENS RESIDENTIAL CARE CENTER
FACILITY NUMBER: 157209256
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/06/2026
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by: Licensee did not ensure
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Licensee agrees to clean R1's room and to make the room free from a maloderous smell by POC due date 02/06/25. LPA will clear POC by visit.
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R1's room is free of a malodorous smell and did not ensure the floor was clean which 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: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 24-AS-20251226163231
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: VERNON GARDENS RESIDENTIAL CARE CENTER
FACILITY NUMBER: 157209256
VISIT DATE: 01/31/2026
NARRATIVE
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Based on interviews and records review, R1 missed all medications from 11/10/25 to 11/24/25.

Based on observation, LPA's went to R1's room. LPA's observed food on the floor. R1's room had a malodorous smell.


Based on the interviews, records review and observation the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, is being cited on the attached LIC 9099D.


A copy of this report with appeal rights and plan of correction was provided.
SUPERVISORS NAME: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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
12/26/2025 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20251226163231

FACILITY NAME:VERNON GARDENS RESIDENTIAL CARE CENTERFACILITY NUMBER:
157209256
ADMINISTRATOR:CUDAL, NANCYFACILITY TYPE:
735
ADDRESS:2603 MOUNT VERNON AVENUETELEPHONE:
(661) 374-8969
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY:54CENSUS: 46DATE:
01/31/2026
UNANNOUNCEDTIME BEGAN:
03:24 PM
MET WITH:Administrator Nancy CudalTIME COMPLETED:
05:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure resident's hygiene needs are being met.
Staff does not ensure resident is provided adequate food service.
Staff leaves resident in bed for extended periods of time.
Staff is wrongfully evicting resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst’ s(LPA’s) Shawna Doucette and Sarah Hurt arrived at the facility unannounced to deliver findings on the allegations listed above. LPA’s explained the purpose of the visit. LPA was granted entry by Administrator Nancy Cudal.

Regarding the allegation Staff does not ensure resident is provided adequate food service. LPA observed facility food has sufficient food supply. Resident 1 stated they do eat meals at the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 24-AS-20251226163231
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: VERNON GARDENS RESIDENTIAL CARE CENTER
FACILITY NUMBER: 157209256
VISIT DATE: 01/31/2026
NARRATIVE
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Regarding the allegation Staff does not ensure resident's hygiene needs are being met. LPA spoke with Resident who stated they do shower and grooming on their own. Resident 1 communicated the facility staff does prompt them to shower and perform daily hygiene tasks. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
Regarding the allegation Staff leaves resident in bed for extended periods of time. Resident 1 is ambulatory and can get in and out of bed on their own. LPA observed Resident 1 get out of the bed and walk down the hallway. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation Staff is wrongfully evicting resident. Facility administrator stated they did have verbal discussion with resident 1 and their caseworker that if resident 1 does not comply with daily hygiene they will be no longer be able to reside at the facility. Resident 1 has not been given a written eviction. Facility administrator stated they are not evicting Resident 1 and have not written eviction notice. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies cited Per title 22 regulations.

Exit interview conducted with facility Administrator Nancy Cudal, and a copy of this report provided.
SUPERVISORS NAME: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6