Garden Manor

Type of visit: Required - 1 Year

On 12/29/2025 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct an annual inspection. LPA met with Supervisor Tara Phillips and Administrator was contacted. Facility has 6 individual apartments which each consisted of 3 bedrooms and one bathroom. There is also a main house with resident rooms and an upstairs apartment. Upon arrival LPA observed various residents to be interacting with staff and among themselves. LPA observed the living arrangements to be clean, odor free, and clutter free. LPA observed fire exits to be free from obstruction. Smoke and carbon monoxide detectors were tested and are in working order. Fire extinguishers were last serviced 6/23/2025 and still have charge. LPA reviewed a sample of resident files to be completed and up to date. LPA also reviewed a sample of staff files and Administrator file which is complete and current. All training for staff is current and up to date. Infection control and disaster plan are complete. LPA reviewed medications. LPA did suggest for facility to store additional non-perishable food items. LPA observed kitchen area and ice machine needing to be lightly cleaned. LPA observed all knives, medications, and cleaning supplies to be locked and inaccessible to residents. LPA observed outside grounds to be clutter free and a covered area for residents. Exit interview was conducted and a copy of this report LIC809 was provided to Supervisor Tara Phillips.the state’s words, verbatim · CDSS document, Dec 29, 2025

Allegation investigated: Facility MAR is incomplete

On March 27, 2025 Licensing Program Analyst (LPA) Rachel Bruce met with Administrative Assistant (AA) to deliver the finding on the above allegation During the course of this complaint investigation LPA interviewed staff and obtained and/or reviewed facility records. It was determined based on the interviews and records review that the above allegation is SUBSTANTIATED. Facility records substantiate the resident in question did receive two doses of medication as prescribed despite the Medication Administration Record only documenting the morning dose. Facility was made aware of the documentation issue and remedied the oversight immediately. The prescribing doctor was notified and was confident the error had been corrected and was confident the staff at Garden Manor would be diligent in ensuring signatures document the provision of medication to the client. Based on LPAs observations and interviews which were conducted and record review(s), 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. Substantiatedthe state’s words, verbatim · CDSS document, Mar 27, 2025 · control 24-AS-20250318134230

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(6) · Plan of correction due date: Mar 27, 2025

Incidental Medical Care (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement was not met as evidenced by Staff dispensed medication without signing the documentation to indicate when the dosage was administered. This poses an immediate risk to the health and safety of the resident in care.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: AA has indicted that the documentation error was remedied and pill audit confirmed the patient did indeed recieve the prescribed medication appropriately. AA has reviewed the medication dispensing procedures with staff specifically to check everytime what the prescrption states and to ensure their intials are documented appropriately. Plan of correction to be cleared at today's visit.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rachel Bruce arrived unannounced to conduct the Annual inspection. LPA met with Assistant Administrator Joanna Tilghman (AA) and explained the purpose of the visit. Facility was toured with AA, including main house, garage and storage areas, outside recreational area, and six resident building units. Resident rooms contained required furnishings and lighting. LPA observed required items in bathrooms. Resident hygiene supplies were properly stored and available as well as extra linen, and overflow of necessary items. In the main house the bathroom water temperature was 108 degrees F. In building 105 the bathroom water temp 108.9 degrees F. In building 106 the bathroom was in use no test was conducted. In building 104 the bathroom water temperature was 106.3 degrees F. In building 103 the bathroom water temperature was 105.4 degrees F. In building 102 the bathroom water temperature measured 104.7 degrees F and in building 101 the bathroom water temperature was 100 degree F. The kitchen was toured and observed to be in good repair with necessary items and appliances. Sharps/knives are stored in drawer, but doors leading to kitchen are kept locked. LPA observed required food supply and paper products. There is a dry storage area kept locked outside the general kitchen area. Canned foods are ordered and delivered on a regular basis however the cans expiration date is listed on the delivery box and not the individual cans. LPA was unable to determine the freshness of food in storage. There are 2 refrigerators in the storage/garage area that hold overflow. Medications are centrally stored and locked. Medical review of distribution records and pill count was completed by LPA. For 11 residents LPA found errors in the distribution. There were no initials only an "X" so there was no way of knowing who gave the medication and secondly there were missing doses and no indication of why, i.e. resident was in hospital, resident refused etc. The AA indicated in those instances it appears to be staff error. First aid supplies located in Main House and found to contain required items. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. The backyard is clean and provides ample space for residents to walk or recreate. Seating is available as well. Fire Extinguishers are located throughout the facility and were serviced by Valley Fire on 6/7/2024. Per Facility record there are 30 smoke detectors which are checked and batteries replaced as needed by maintenance. Records of smoke alarm checks can be found in maintenance binder. Last documented inspection was June 3, 2024. LPA reviewed Jorgensen & Co. Fire Alarm System Service Report dated September 13, 2024. On that date sprinklers were inspected by the Fire Department and Jorgensen jointly. The report indicates the facility failed the inspection due to an issue with 2 automatic sprinkler heads located outside. The necessary repair/replacement was completed and a re-inspection completed on 12/10/24. AA will forward successful report to CCL when received. Administration certifications are current. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D. An exit interview was conducted and a Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and will be provided to AA. At the time the inspection was over, AA was not available to sign so Bonnie Martin, House Manager was given permission to sign. LPA is requesting the following documents be submitted to the Fresno CCL office by 1/12/2025: Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), and Register of Facility Clients/Residents for (LIC9020A).the state’s words, verbatim · CDSS document, Dec 16, 2024

Type of visit: POC

Licensing Program Analyst (LPA) L.Padgett conducted an unannounced POC visit and met with facility Assistant Administrator Joanna Tilghman (AD) to verify correction of citation 87303(e)(2) issued during Annual Inspection conducted on 1/4/2024. LPA and AD toured the 7 buildings at this facility and water temperature was check in the bathrooms. Water temperature was as follows: Main House 106.4 and 105 degrees F. Building 1, 110.1 degrees F. Building 2, 105.4 degrees F, Building 4, 116.7, Building 5 110.8 degrees F, Building 6 118.9 degrees F. Building 3 was not rechecked by LPA as it was being used by a resident. Per maintenance notes on 1/5/24 to AD temperature was noted to be 112 degrees F. Letter of Deficiency Citations Cleared provided to AD.the state’s words, verbatim · CDSS document, Jan 8, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lissett Padgett arrived unannounced to conduct the Annual inspection. LPA met with Assistant Administrator Joanna Tilghman (AD) and explained the purpose of the visit. Facility was toured with AD. Resident rooms contained required furnishings and lighting. LPA observed required items in bathrooms. Resident hygiene supplies were properly stored and available. In building 104 the bathroom water temperature was 144 degrees F. In building 105 the bathroom water temp 119.2 degrees F. In building 106 the bathroom water temperature was 127.1 degrees F. The kitchen was toured observed in good repair with necessary items and appliances. Sharps/knives are stored in drawer, but doors leading to kitchen are kept locked. LPA observed required food supply and paper products. Medications are centrally stored and locked. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. First aid supplies located in office and found to contain required items. Fire Extinguishers are located throughout the facility and were serviced by Valley Fire on 7/17/2023. Per Facility record there are 30 smoke detectors and they were last checked and batteries changed on 10/5/2023. LPA reviewed Jorgensen & Co. Fire Alarm System Service Report dated 8/14/2023. This Report states this facility did not pass inspection. During this visit AD called Jorgensen and requested service to replace items not in compliance. Sprinklers were last inspected by the Fire Dept. on 8/14/2023. Administrator’s re-certification was confirmed to be in active status. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D. An exit interview was conducted and a Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with AD, whose signature on this form confirms receipt of these documents. LPA is requesting the following documents be submitted to the Fresno CCL office by 1/12/2024: Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bondthe state’s words, verbatim · CDSS document, Jan 4, 2024

Allegation investigated: Staff did not ensure facility was kept free of pests.

A Complaint visit was conducted on the date & time above. Licensing Program Analyst (LPA) K. McClurg called posted phone number for drive-in gate to be opened. LPA spoke with Administrator Assistant (AA) Joanna Tilghman over the phone, stated purpose of visit, & AA agreed to have House Manager (HM) Bonnie Martin. Pest Control services contacted immediately. Pest Control Service receipts/invoices support this along with continued treatment until could complete & confirm eradication of bed bugs. Facility followed appropriate policies and procedures. The Department has investigated the above allegation & determined it to be Unfounded. Exit interview conducted with HM. Report provided. Unfoundedthe state’s words, verbatim · CDSS document, Oct 30, 2023 · control 24-AS-20230817142722

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.