107208983-8-6-2025-24-AS-MGAA-DKAREY-20250806125819

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107208983
Report Date: 08/06/2025
Date Signed: 08/06/2025 12:58:26 PM

Document Has Been Signed on 08/06/2025 12:58 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	SUMMERFIELD OF FRESNO		FACILITY NUMBER:	107208983
ADMINISTRATOR/ DIRECTOR:	HUNTLEY, ROBERT		FACILITY TYPE:	740
ADDRESS:	6075 N. MARKS		TELEPHONE:	(559) 446-6226
CITY:	FRESNO	STATE: CA	ZIP CODE:	93711
CAPACITY: 64		CENSUS: 53	DATE:	08/06/2025
TYPE OF VISIT:	Office	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Regional Vice President of Operations, Dan Gormley		TIME VISIT/ INSPECTION COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On this date, an office meeting was conducted to discuss concerns identified by the Department, the operations of the facility, and the number of complaints received for Summerfield of Fresno. Present during the meeting were: Brenda White, Regional Manager See Moua, Licensing Program Manager Mary Garza, Licensing Program Analyst Dan Gormley, Regional VP of Operations newly hired Executive Director/Administrator, effective 8/4/25 Steve Kregel, COO/Owners On 2/12/25, a Non-compliance meeting (NCC) was conducted to discuss the citations issued by the Department. At this time, issues regarding care and supervision, meeting resident’s personal and hygiene needs, safe guarding resident’s personal belongings, ensuring that hazardous items and materials were inaccessible, and staff training were discussed. The Department also addressed concerns related to Food Services, staff and resident’s records, staffing, and seeking timely medical attention. During the NCC, the facility representatives provided plan of corrections to the Department to address the issues. It was stated that the facility had hired a new Administrator/Executive Director and LVN who would address these issues. CONT...

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/06/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/06/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

CONT...
Since the NCC, in the span of 6 months, the Department received 14 complaints. The complaints alleged concerns related to care and supervision, staffing, resident’s hygiene, a Scabies outbreak, staff training, and food. In addition, case management deficiencies were issued for: Reporting Requirements, Fire Clearance with Civil Penalty, and Reappraisals.

During today’s meeting, findings were delivered for complaints. Allegations where the preponderance of evidence were met were Substantiated. Civil penalties were issued.

During the meeting, the facility representatives were asked to provide Proof of Corrections for the deficiencies cited and addressed the concerns observed by the LPA. The concerns were: lack of management oversight, staffing, staff accountability, Executive Director/Administrator’s Qualifications and Duties to be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility.

COO and VP of Operations stated former Administrator/ED Rob and LVN Gabe wasn’t transparent and did not communicate issues.

Proof of corrections provided were:
The facility will submit a plan regarding the proof of corrections below by 8/20/25 –
1. Care and Supervision: Hygiene Needs/Incontinence Care
2. Resident’s Files and Re-assessment
3. Staff Training
4. Food
5. Buildings and Grounds

-Regarding the Scabies: Local CDPH was contacted and are following Infection Control, Clinical Oversight Nurse by Allen Flores is coming in, skin checks will be done
-Staffing and Communicate with Families – townhall meeting with resident’s families,
-Accountability and Administrator Qualifications – Leadership member will work past regular hours, ED stated work hours as reflected on the LIC 500, Hired outside service for Satisfaction Surveys effective July 2025
-Implement Stand up and Stand down
-Implement Communications log

The facility was informed that at this time, the Department will be seeking appropriate Administrative Actions. An exit interview was conducted and appeal rights were provide for citations issued for the complaints.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/06/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3