The Terraces at San Joaquin Gardens

Allegation investigated: Staff do not provide adequate food service Staff yelled at resident Staff speaks inappropriately to residents Staff interacts inappropriately with residents

Licensing Program Analyst (LPA) Daiquiri Boyd conducted the complaint investigation visit to the facility. During this visit LPA obtained copies of internal investigation that was conducted and interviewed staff. LPA delivered investigation findings regarding the above allegations on this day. The Department has investigated the complaint alleging: Staff do not provide adequate food service, staff yelled at resident, staff speaks inappropriately to residents, staff interacts inappropriately with residents. Based on the interviews conducted and/or records review the above allegations are UNSUBSTANTIATED. LPA found no coorberating evidence or statements. LPA's interviews revealed that no one, including residents and supervising staff, has ever witnessed the staff acting inappropriately. Interviews reveald that residents were happy with food service at the time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 2, 2026 · control 24-AS-20260617090730

Allegation investigated: Staff refuse resident visitors

Licensing Program Analyst (LPA) Daiquiri Boyd conducted the unannounced 10 Day complaint investigation visit to the facility. During the course of this complaint investigation LPA interviewed staff on duty and obtained and/or reviewed facility records. It was determined based on the interviews and records review that the above allegation is SUBSTANTIATED. The staff did not allow a visitor to see a resident placed in care. 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(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. Substantiatedthe state’s words, verbatim · CDSS document, May 19, 2026 · control 24-AS-20260512112521

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Jun 2, 2026

Personal Rights of Residents in All Facilities-To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed infringed upon. This requirement is not met as evidenced by staff did not allow a resident's family member to visit them while placed at the facility; which poses a potential risk to the health, safety, or personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, May 19, 2026

Plan of correction: Facility will conduct the retraining of "Point Staff Personnel" on the Visitation Policy and Resident Personal Rights to ensure regulation is followed. Proof of retraining will be submitted to Licensing by 6/2/26.

Type of visit: Required - 1 Year

On 02/25/2026, Licensing Program Analyst (LPAs) Daiquiri Boyd and Sarah Hurt arrived unannounced to conduct a required annual inspection. LPA met with Director, Valerie Epps and announced the purpose of the visit. LPAs toured lodges: Antonella, Tivoli, Tulipano, Piazza, Tuscany and Grove inside and out. LPAs walked through Independent Living residences, Assisted Living residences, and Memory Care residences. LPAs checked water temperatures; in a sample of bathroom or kitchen temperature readings, lowest 113 degrees F and highest 118 degrees F. In most units on the grounds, they have installed tank-less water heaters. Kitchen toured and food stored properly for perishable and nonperishable in each kitchen for each lodge. Medication is locked and stored in a medication cart in each lodge. All seven resident rooms observed during this annual inspection were properly furnished, had adequate lighting, and storage space. Smoke detectors and carbon monoxide were checked and found to be operational. Wet pipe fire sprinkler system is inspected annually February though a site wide inspection with local service provider. All fire extinguishers examined throughout the tour, in all buildings, were serviced February 2026. Quarterly disaster and fire drills were recorded in a binder, noting each type of drill performed, time and focus of the type of drill and who attended. A review of staff and resident files was completed. Plan of Operation was complete. Infection Control Plan was complete. No deficiencies and citations were issued at this time. Exit interview was conducted with Director, Valerie Epps and Administrator Alexis Case.the state’s words, verbatim · CDSS document, Feb 25, 2026

Type of visit: Case Management - Incident

On 05/28/2025, Licensing Program Analyst (LPA) Daiquiri Boyd made an unannounced visit to the facility for the purpose of a Case Management review of a Death Report that was submitted to the Department on May 13, 2025. LPA met with Director of Assisted Living and Wellness (DOW), Valerie Epps. LPA reviewed water test results and interviewed DOW. Director of Buildings and Grounds,(DOBG) Brian Evans, spoke with LPA and also explained photos of the water tests and forwarded the pictures to LPA. All water test results were negative for any bacterial presence. DOW explained to LPA that in cross-reporting, they notified Fresno County Health Department (FCHD). All water tests were reviewed by LPA Boyd and pictures of the water tests are attached to this report and explained an a separate LIC812. Interviews conducted on this day are recorded on an LIC812. An explanation and a copy of this report was given to DOW, whose signature on this report confirms it's receipt.the state’s words, verbatim · CDSS document, May 28, 2025

Type of visit: Required - 1 Year

On 01/13/2025, Licensing Program Analyst (LPAs) Daiquiri Boyd and Melinda Medina arrived unannounced to conduct a required annual inspection. LPA met with Director, Valerie Epps and announced the purpose of the visit. LPAs toured lodges: Antonella, Tivoli, Tulipano, Piazza, Tuscany and Grove inside and out. LPAs walked through Independent Living residences, Assisted Living residences, and Memory Care residences. LPAs checked water temperatures; in a sample of bathroom or kitchen temperature readings, lowest 110 degrees F and highest 119.4 degrees F. In most units on the grounds, they have installed tank-less water heaters. Kitchen toured and food stored properly for perishable and nonperishable in each kitchen for each lodge. Medication is locked and stored in a medication cart in each lodge. All ten bedrooms observed during this annual inspection were properly furnished, had adequate lighting, and storage space. Smoke detectors and carbon monoxide were checked and found to be operational. Wet pipe fire sprinkler system is inspected annually February though a site wide inspection with local service provider. All fire extinguishers examined throughout the tour, in all buildings, were serviced February 2024. Quarterly disaster and fire drills were recorded in a binder, noting each type of drill performed, time and focus of the type of drill and who attended. LPA Medina recorded staff and resident files on a separate form on this date. A review of staff and resident files was completed. No deficiencies and citations were issued at this time. Exit interview was conducted with Director, Valerie Epps.the state’s words, verbatim · CDSS document, Jan 13, 2025

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.

Allegation investigated: Resident sustained 2 stage 4 pressure injuries, fractured pelvis, and internal bleeding due to staff neglect Facility does not have enough staff to meet residents needs Facility staff failed to conduct appraisals to meet resident’s change of condition

On 07/23/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings on the above allegations. LPA introduced self, stated the purpose of the visit and reqeusted to meet with the Administrator. LPA met with Director of Assisted Living and Wellness, Valerie Epps Based on interviews and records review, R1 sustained a witnessed fall resulting in R1 sustaining injuries and staff seeking emergency medical treatment. Due to R1's level of independence it was determined that facility staff could not have prevented the fall. Review of records revealed that no pressure wounds were observed upon admission to the hospital. R1 was transferred to another hospital for a higher level of care, where R1 was examined and a pressure wound was observed. R1 was later discharged to a skilled nursing facility where the pressure wound worsened. The Department has investigated the allegations: Resident sustained 2 stage 4 pressure injuries, fractured pelvis, and internal bleeding due to staff neglect, Facility does not have enough staff to meet residents needs, Facility staff failed to conduct appraisals to meet resident’s change of condition. CONTINUED TO 9099C Unsubstantiated The Department has found that the allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies issued during today's inspection. Exit interview conducted. A copy of this report was discussed and provided to Director of Assisted Living and Wellness, Valerie Epps, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Jul 23, 2024 · control 24-AS-20240318085012

Type of visit: Case Management - Annual Continuation

On 2/12/2024, Licensing Program Analyst (LPA) M. Flores arrived unannounced to continue the required annual inspection. LPA explained reason for inspection and was granted entry by Director, Valerie Epps. LPA completed inspection of the pool, evacuation chair, and locked cabinet for sharps. During the visit a sample of resident’s file was conducted; refer to 809D for deficiencies. Exit interview was conducted with Director, Valerie Epps, whose signature confirms receipt of this report. Received a copy of Appeal Rights.the state’s words, verbatim · CDSS document, Feb 12, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 02/08/24, Licensing Program Analyst (LPA) M. Flores arrived unannounced to conduct a required annual inspection. LPA met with Director, Valerie Epps and announced the purpose of the visit. LPA toured lodges, Antonella, Tivoti, Tulipano,Valencia and Grove inside and out. LPA checked water temperature in a sixteen-bedroom sample, bathroom temperature read, lowest 106.3 degrees F and highest 134 degrees F. LPA observed fire extinguishers and were last service on 12/04/2023 and 2/10/23. Kitchen toured and food stored properly for perishable and nonperishable in each kitchen for each lodge. Medication is locked and stored in a medication cart. All sixteen bedrooms observed during this annual inspection were properly furnished, had adequate lighting, and storage space. Smoke detectors and carbon monoxide were last checked on 2/8/2024 for Antonella; Valencia, Tivoti, Tulipano, and the Grove were inspected last inspected on 2/07/24. A sample of staff files was completed. Interviews of staff and residents was completed. Due to time constraints annual inspection was not completed at this time. No deficiencies and citations were issued at this time. LPA will return to the facility on another date to complete this annual inspection. Exit interview was conducted with Director, Valerie Epps.the state’s words, verbatim · CDSS document, Feb 8, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Miriam Flores arrived unannounced to the facility to conduct a Case Management Visit. LPA met with Director, Valerie Epps. LPA explained the purpose of the visit. This case management visit is to follow up on self reported incidents to Community Care Licensing (CCL). Special Incident Reports (SIR) are dated 11/30/23 and 12/06/23. File reviews and interview were completed. At this time, this case is under review by CCL. No deficiencies cited during today’s visit. An exit interview was completed with Director, Valerie Epps.the state’s words, verbatim · CDSS document, Dec 13, 2023