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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209256
Report Date: 04/22/2026
Date Signed: 04/27/2026 09:02:53 AM

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
04/16/2026 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20260416122116
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:
04/22/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Nancy CudalTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not seek medical attention to resident in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to investigate allegations listed above. LPA met with facility Administrator Nancy Cudal, and explained the purpose of today's visit.

On 04/22/2026, LPA interviewed staff 1 , who stated that at approximately 7:40 AM on 04/13/2026, they observed resident 1 in the dining area and noted his face appeared dirty. Staff1 stated that upon further observation, they saw what appeared to be dried blood under the resident’s eye. Staff 1 reported they asked the resident multiple times if they was okay and offered to call an ambulance, doctor, or seek medical attention; however, the resident repeatedly declined and stated they were “okay.”

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026
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 3
Control Number 24-AS-20260416122116
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: 04/22/2026
NARRATIVE
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Staff 1 stated they did not further assess the injury as the resident became agitated and refused assistance. Staff 1 also stated that although they suspected the resident may have been injured, they did not notify the administrator at that time and did not seek medical attention for the resident. Staff 1 stated they documented the incident later in their shift. LPA also interviewed facility Administrator, who stated they became aware of the incident after reviewing staff notes and that the resident was later sent for medical evaluation. Based on interviews conducted, staff observed a visible injury to the resident and acknowledged concern that the resident may have been injured. However, staff 1 failed to notify administration in a timely manner or ensure the resident received timely medical assistance. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.



The following deficiencies are being cited Per Title 22 Regulation.

Exit interview conducted with facility Administrator Nancy Cudal, and a copy of this report along with appeals rights provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20260416122116
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: 04/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/23/2026
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.The following requirement has not been met as evidenced by:
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Administrator will send proof of In service training provided to staff on providing timely care to facility residents and submit to LPA by POC date of 04/23/2026.
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Facility staff did not provide timely medical care to resident 1 despite visible injury, which poses an immediate, health, safety, 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: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3