The Gardens of Modesto

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Melina Oropeza and Licensing Program Manager (LPM) Liza King arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA was met by staff and administrator, Mark Chisum. LPA explained the purpose of the visit to Administrator and staff. Administrator certificate # 6074900740 expires 02/03/2027. Facility is a 73 bed facility with a current census of 37. This facility is licensed to served residents who are 60 and over, approved for 73 non-ambulatory, of which 10 may be bedridden. Approved hospice waiver for 12 residents. It was learned that there were a total of 9 residents on hospice. LPA and administrator toured the facility, including the main building, which consists of 4 separate wings: Napa, Central Valley, Yosemite and Carmel (not occupied). LPA observed a small kitchenette that is equipped with microwave and an addition refrigerator present to cool, heat, and warm up food of the residents if necessary. Resident bedrooms were observed to be equipped with an alert system. Resident bathrooms were also toured. Hot water temperature was measured at 114 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. It was learned that this facility has a signal alert system in resident bathrooms. Resident rooms were sanitary and had the required furniture and furnishings. LPA also toured laundry area, living area and other common areas, to ensure compliance with Title 22 regulations. LPA observed the facility to be clean and free of odors. LPM observed several residents participating in several activities during the day. LPA also conducted the care domain tool. No bodies of water were observed at the facility. LPA toured the kitchen and dining room area. LPA observed residents having lunch in the dining room area. Facility freezer and refrigerator units were toured. LPA observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. LPA observed that the air conditioning unit in the kitchen was not operational. Kitchen manager reported the replacement part was ordered on 09/14/2026, and facility is awaiting for the part to complete repair. LPA toured the storage area for chemicals and cleaning supplies were observed to be locked and made inaccessible to the residents at this time. LPA toured the facility's medication room and observed medication storage. The facility utilizes the QMAR electronic medication management system to document and track residents MARS. 2 of 2 centrally stored logs were not completed. Pill counts were off for 2 of 2 reviewed. LPM verified with med tech on duty additionally, Narcotics were reviewed 2 of 2 and were accurate. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils. LPA observed, fire extinguishers inspected on 07/15/2026 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance. LPA toured the exterior grounds. Perimeter fence and gates were observed. It was observed that the black gate next to the exit gate was left unlock. LPM observed 2 window screens in need of repair. LPA reviewed facility documentation, including, Resident Council meeting notes (08/21/2026), the Infection Control Plan, Emergency Disaster Plan and fire drill logs. LPA reviewed ten (10) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required. LPM conducted follow-ups regarding ten(10) SIR's and reviewed the resident's files cont.. 8 resident files reviewed including associated MARS. LPM King identified through file review and interview with the Administrator the following areas which require attention; R1 did not have an updated Needs and Services Plan (NS Plan) following a fall with injury, R2's MAR was not updated following a DC from the hospital, R3 no signature of resident or responsible party on the updated care plan, no verification of a care conference could be provided, additionally resident had several falls and a prn order for a pain reliever which was not administered, Review of the MAR shows pm meds on 08/13/26 not signed off, R4 no signature of resident or responsible party on the updated care plan, no verification of a care conference could be provided, additionally although a medication was prescribed by the MD the family refused to pay for the medication therefore it was not provided. Documentation of correspondence with MD was delayed for a month with the resident not receiving the medication although exhibiting symptoms related to anxiousness and frustration which the medication is used to alleviate, R5 no signature of resident or responsible party on the updated care plan, no verification of a care conference could be provided, additionally hospice care plan not in file nor documented on the NS Plan, R6 no signature of resident or responsible party on the updated care plan, no verification of a care conference could be provided, R8 no signature of resident or responsible party on the updated care plan, no verification of a care conference could be provided, additionally not updated to include care of a restricted health condition or hospice care, Hospice CP not included in file, Review of the MAR shows pm meds on 08/13/26 not signed off. The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code. Exit interview was conducted with administrator, Mark Chisum and copies of reports and appeals given at conclusion of visit.the state’s words, verbatim · CDSS document, Sep 29, 2026

Allegation investigated: Facility is using delayed egress without proper authorizations.

On 05/12/26, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to deliver complaint findings for the allegation above. LPA Pascua met with Facility Designated Administrator (FDA), Lindsay Beckett and explained the purpose of the visit. Current Census was 34. A brief interview with FDA Beckett was conducted. It was alleged that the facility was using delayed egress without proper authorization. Based on documentation reviewed by the department, it was determined that the facility obtained the appropriate fire clearance for delayed egress in September 2022. Additionally, a review of the facility’s Plan of Operation confirmed that it includes documentation outlining the use of delayed egress and the associated procedures for the facility. Based on the information gathered, This agency has investigated the complaint allegation(s). This agency has found that the complaint was UNFOUNDED, meaning that the allegation(s) were false, could not have happened and/or was without a reasonable basis. This agency has therefore dismissed the complaint. There were no deficiencies observed or cited during today’s complaint visit. A copy of this report was provided to the facility at the end of this visit. Unfoundedthe state’s words, verbatim · CDSS document, May 12, 2026 · control 27-AS-20260429093318

Type of visit: Case Management - Deficiencies

On 04/30/2026, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA Pascua met with Facility Designated Administrator (FDA), Lindsay Beckett and explained the purpose of this visit. The purpose of this visit was to follow up on an incident report that was sent to the department on 03/30/2026. It was learned that the date of the incident occurred on 03/18/2026, which were outside of the reporting requirements of seven days by Title 22. Based on the information gathered deficiencies are being issued today during today's visit. An exit interview was conducted, appeals rights, and a copy of this report will be provided to this facilitythe state’s words, verbatim · CDSS document, Apr 30, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: May 30, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This is not met as evidenced by: The licensee did not ensure that an incident report was sent to the department within 7 days. This poses a potential health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Apr 30, 2026

Plan of correction: The facility will undergo training from a vendorized trainer for no less than (1) hour in duration on the topic of reporting requirements. A statement of correction and acknowledgement along with documented proof of scheduled training topics, dates, and times will be completed and submitted into CCL by the due date.

Type of visit: Case Management - Incident

On 02/11/2026, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA Pascua met with Facility Designated Administrator (FDA), Lindsay Beckett and explained the purpose of the visit. The purpose of this visit was to follow up on an Special Incident Report (SIR) that was received by the department 02/05/2026. The SIR states that on 02/04/2026, R1 became combative towards staff resulting in injury. LPA Pascua reviewed R1's Pre-Appraisal, Needs and services plan and care plan. LPA Pascua also conducted an interview with FDA Beckett. Based upon interviews and facility records there were no deficiencies that were cited during this case management visit. LPA Pascua will come at a later time if further follow up is needed. A copy of this report was provided to the facility and an exit interview was conducted.the state’s words, verbatim · CDSS document, Feb 11, 2026

Type of visit: Required - 1 Year

On 08/28/2025, Regional Manager (RM), Stephenie Doub and Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. RM Doub and LPA Pascua were greeted by Facility Designated Administrator (FDA), Ravjir Sandhu and explained the purpose of the visit. The purpose of the visit was to conduct an annual visit. Current census was 41. A brief interview with FDA Sandhu was conducted. This facility is licensed to served residents who are 60 and over with a capacity of 73. 73 of 73 residents may be deemed non-ambulatory. 10 of 73 may be bedridden. This facility also has a hospice waiver for 16 residents. It was learned that there were a total of 11 residents on hospice. LPA reviewed 5 resident files and 5 staff files. It was observed that 5 out 5 resident files did not have an updated Needs and Services Plan. It was observed that 1 out 5 staff did not have an First Aid/CPR on file. 1 out of 5 staff did have First Aid however CPR was not on file. 1 out 5 staff files did not have the mandated reporter statement signed and 1 out 5 staff files did not have their application on file. The Facility Designated Administrator has an active certificate #6069560740 and expires on 11/20/2026. LPA reviewed that fire drill log and is in compliance at this time. A tour of the facility was conducted with FDA Sandhu. This facility has a main building in which has 4 separate wings, Napa, Central Valley, Yosemite and Carmel. Currently, there are no residents residing in Carmel. A separate building, Monterey was also observed and toured. LPA observed a small kitchenette that is equipped with microwave and an addition refrigerator present to cool, heat, and warm up food of the residents if necessary. It was learned that resident bedrooms have been equipped with pull cords were observed. A review of the resident restrooms was conducted. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees. It was learned that this facility has a signal system in resident bathrooms. LPA Pascua observed a fire extinguisher in Monterey and all wings that were services by Fire Master on 08/06/2025 and is in compliance at this time. Kitchen area was toured. Facility freezer and refrigerator units were toured. LPA reviewed the food storage supply to make sure that there was always a 2-day perishable and 7-day nonperishable food quantities on site at all times. Storage area for chemicals and cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Additional incontinent supplies were also identified. A medication room was identified and tour. Medication carts for all four wings was reviewed and the policies for dispensing, storing, and documentation was discussed with facility staff responsible for the medication management at this time. It was observed while comparing Electronic Medication Administration Record that the facility did not have an order for R1's medication on file. Further review shows that the facility did not have this medication on the EMAR since 01/15/2025. In addition, it was observed that the facility had medication poured into plastic containers for noon medication pass. First aid kit was observed to be present and contained all of the required components at this time. Perimeter fence and gates were observed. It was observed that the black gates next to the exit gate had a padlock attached which prohibited access to the back gate. The following forms and documents were requested to be updated and submitted into CCL for review by this LPA: LIC 308 LIC 400 LIC 500 LIC 610 Licensees were offered and agreed to an opportunity to participate in Department's Technical support Program. The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Aug 28, 2025

Type of visit: Required - 1 Year

On 09/26/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA met with Facility Designated Administrator (FDA), Stephenie Radu and explained the purpose of the visit. Current census was 37. A brief interview with FDA Radu was conducted. This facility is licensed to served residents who are 60 and over with a capacity of 73. 73 of 73 residents may be deemed non-ambulatory. 10 of 73 may be bedridden. This facility also has a hospice waiver for 16 residents. It was learned that there were a total of 6 residents on hospice, 0 residents who are bedridden, and 3 residents receiving home health services at this time. LPA reviewed 8 resident files and 5 staff files. All resident and staff files were current and up to date. The Facility Designated Administrator has an active certificate #600701740 and expires on 08/31/2025. LPA reviewed that fire drill log and is in compliance at this time. A tour of the facility was conducted. This facility has a main building in which has 4 separate wings, Napa, Central Valley, Yosemite and Carmel. Currently, there are no residents residing in Carmel. A separate building, Monterey was also observed and toured. LPA observed a small kitchenette that is equipped with microwave and an addition refrigerator present to cool, heat, and warm up food of the residents if necessary. All buildings were toured. LPA Pascua toured a bedroom from each wing and observed all furniture and furnishing to be in good repair and in compliance at this time. It was learned that resident bedrooms have been equipped with pull cords were observed. A review of the resident restrooms was conducted. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees. It was learned that this facility has a signal system in resident bathrooms. LPA Pascua observed a fire extinguisher in Monterey and all wings that were services by Jorgenson Co. on 10/17/2023 and is in compliance at this time. Along with the Maintenance director, the LPA tested and observed that smoke detectors and carbon monoxide in rooms and in hallways to be in good repair. Kitchen area was toured. Facility freezer and refrigerator units were toured. LPA reviewed the food storage supply to make sure that there was always a 2-day perishable and 7-day nonperishable food quantities on site at all times. Storage area for chemicals and cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Additional incontinent supplies were also identified. A medication room was identified and tour. Medication carts for all four wings was reviewed and the policies for dispensing, storing, and documentation was discussed with facility staff responsible for the medication management at this time. First aid kit was observed to be present and contained all of the required components at this time. A tour of the laundry rooms were conducted. The facility has a total of 3 washers and 3 dryers at this time. Exterior grounds of this facility was toured. Perimeter fence and gates were observed to be functional and in good repair at this time. Delayed egress and other safety measures were observed to be functional at this time. The following forms and documents were requested to be updated and submitted into CCL for review by this LPA: LIC 308 LIC 400 LIC 500 LIC 610 A technical violation is being provided today for Section 87312 and was discussed with the Facility Designated Administrator. Based on the observations made during this visit, no citations are being provided during this visit. An exit interview was conducted and a copy of this report was provided at the end of this visit.the state’s words, verbatim · CDSS document, Sep 26, 2024

Type of visit: Case Management - Other

On 11/20/23 at approximately 10:30am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management in relation to an incident report received. LPA Jensen met with Executive Director Theresa Pettapiece and explained the purpose of today's visit. On 10/26/23 the Department received an incident report indicating that Resident 1 (R1) had an unwitnessed fall. Per facility protocol for unwitnessed falls, the resident was taken to the Emergency Department of the hospital and it was determined that she sustained a spinal fracture to L2. LPA Jensen interviewed the Executive Director and R!. LPA Jensen reviewed records including the Plan of Operation, R1's physician report, charting notes, pre-placement appraisal and needs and service plan. LPA Jensen observed lunch service during the course of the visit. During the annual inspection of 9/14/23, the facility was cited for a signal system in-operability and/or malfunctioning. The facility requested an extension for the plan correction through December 13, 2023. LPA Jensen discussed the facility's need to have an alternate plan for care and supervision so that resident needs can be met while the signal system is being upgraded. Technical assistance is being provided in the areas of signal systems, plan of operations and special diets. No deficiencies are being cited as a result of this visit. An exit interview was conducted with Theresa Pettapiece and and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 20, 2023