Village Gardens

Allegation investigated: Staff mismanaged resident's medication Staff increased the resident's fees without a proper notice

On 4/09/26, Licensing Program Analyst (LPA) M. Medina conducted an unannounced initial 10-day visit complaint visit. LPA arrived, stated purpose of visit, and allowed entrance by staff. LPA met with Operations Manager, Alfredo Benavides to conduct visit with LPA. This department has investigated the above allegations. During the course of the investigation, LPA toured the facility, conducted interviews, and reviewed documentation. Based on interviews conducted, it was reported that there were pills in R1's bedroom, when found they were provided to staff 2 (S2). During visit on this date, resident 2 (R2) provided a pill to LPA that was found at dining room table belong to resident 3 (R3). Responsible party for R1 was notified verbally on 3/22/26 and via text message on 3/30/26 of a rate increase effective 4/01/26. The change of change of condition for R1 occurred on 2/21/26. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D. Exit interview conducted and a copy of this report was provided for facility records. Substantiatedthe state’s words, verbatim · CDSS document, Apr 9, 2026 · control 24-AS-20260407141704

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 10, 2026

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self administered medication as needed. ***This was not met as evidenced by it was reported that there were pills in R1's bedroom, when found they were provided to staff 2 (S2). During visit on this date, resident 2 (R2) provided a pill to LPA that was found at dining room table belong to resident 3 (R3).the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: Administrator to provide medication training for staff. Facility to submit agenda to Fresno Regional office by 4/10/2026. Sign in sheets will be provided to Fresno Regional office after staff meeting is conducted but no later than 4/24/2026.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.657 · Plan of correction due date: Apr 24, 2026

(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges. ***This was not met as evidenced by Responsible party for R1 was notified verbally on 3/22/26 and via text message on 3/30/26 of a rate increase effective 4/01/26. The change of change of condition for R1 occurred on 2/21/26.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: Administrator to review regulation and submit written statement to Department that Health & Safety Code 1569.657 has been read.

Allegation investigated: Staff are not adhering to the admission agreement

On 02/07/2025, Licensing Program Analyst (LPA) M. Medina conducted an unannounced initial 10-day visit complaint visit. LPA introduced self, stated purpose of visit, and allowed entrance by direct care staff. Administrator contacted by telephone and arrived a short time later to conduct visit with LPA. This department has investigated the above allegation. During the course of the investigation, LPA toured the facility, conducted interviews, and reviewed documentation. Based on LPA review of documentation, the admission agreement states that basic services includes 1) three nutritious meals per day and 2) special diets if prescribed by a doctor. Correspondence from licensee states that additional food costs for a special diet would be a charged rate without an addendum to the admission agreement. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D. Exit interview conducted and a copy of this report was provided for facility records. Substantiatedthe state’s words, verbatim · CDSS document, Feb 7, 2026 · control 24-AS-20260130104916

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(B)(1) · Plan of correction due date: Feb 23, 2026

(g) Admission agreements shall specify the following: (B) Rate for additional items and services, including: 1.A comprehensive description of and the corresponding fee schedule for all additional items and services not included in the fees for basic services shall be listed. ***This was not met as evidenced by the admission agreement states that basic services includes 1) three nutrituous meals per day and 2) special diets if prescribed by a doctor. Correspondence from licensee states that additional food costs for a special diet would be a charged rate without and addeddum to the admission agreement.the state’s words, verbatim · CDSS document, Feb 7, 2026

Plan of correction: Licensee will provide a written that states any addendums to admission agreement must be in writing and adhere to Title 22 regulation 87507.

Allegation investigated: Staff did not maintain a comfortable temperature in the facility for residents

On 02/07/2025, Licensing Program Analyst (LPA) M. Medina conducted a subsequent unannounced complaint visit to conduct interviews and deliver findings. LPA introduced self, stated purpose of visit, and allowed entrance by direct care staff. Administrator contacted by telephone and arrived a short time later to conduct visit with LPA. During the course of the investigation, LPA toured the facility, conducted interviews, and reviewed documentation. On initial visit conducted on 1/08/2026, LPA observed both facility thermostats within facility to be 72 degrees F and the thermometer in R1's bedroom was 71 degrees F. During the subsequent visit on 2/07/2026, LPA observed facility thermostats to be 72 degrees F and 74 degrees F, the thermometer in R1's bedroom was 74 degrees F. The department has insufficient information regarding the above allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or disprove that the allegation occurred therefore the allegation is UNSUBSTANTIATED. Nothe state’s words, verbatim · CDSS document, Feb 7, 2026 · control 24-AS-20251230111612

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Katie Brown conducted a Case Management in conjunction with an initial complaint visit. LPA met with and explained the reason for the Case Management with Administrator (AD) Margaret Benavides. During this visit, LPA observed a chef's cooking knife unattended on the kitchen counter. AD immediately removed the knife and secured it in locked storage as required. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and provided via email.the state’s words, verbatim · CDSS document, Jan 8, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(a) · Plan of correction due date: Jan 9, 2026

87309 Storage Space and Access (a)... licensee shall ensure that, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidenced by: Licensee did not ensure that items which could pose a danger to residents were locked or stored inaccessible to residents. A chef cooking knife was left unattended on the kitchen counter while residents were present. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 8, 2026

Plan of correction: AD immediately removed the knife and locked it up as required. DEFICIENCY CLEARED DURING VISIT

Type of visit: Case Management - Annual Continuation

On 11/04/2025, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Continuation visit to facility. LPAs introduced self, stated purpose of visit and allowed entrance by Direct Care Staff. LPA met with House Manager, Margaret Gardea to conduct visit. LPAs reviewed a sample of staff files and resident files, files reviewed and observed to have the required documentation. LPAs interviewed staff and resident. Inspection tool completed. Exit interview conducted with Administrator. A copy of this report was provided at the time of visit. No deficiencies cited.the state’s words, verbatim · CDSS document, Nov 4, 2025

Type of visit: Required - 1 Year

On 10/28/2025, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA introduced self, stated purpose of visit and allowed entrance into facility by Direct Care Staff. Margaret Gardea contacted by telephone and arrived a short time later to conduct visit with LPA. Currently, six (6) residents in care. residents were all present during today's inspection. Residents were observed to be relaxing in the family room, resting in their bedroom, and preparing for their meal. All common area observed to have adequate seating and lighting available for residents. Resident bedrooms toured, all bedrooms observed to have required furnishings and linens observed to be clean and in good repair. Resident bathrooms toured, fixtures observed to be clean and operational during inspection. Showers observed to have grab bars, skid-resistant mats, and shower chairs available. Water temperature measured at 113 degrees F. Kitchen tour conducted, a 2-day supply of perishable and a 7-day supply of non-perishable food present and properly stored. All knives are stored and secured in cabinet in laundry room. Medications observed to be locked and secured in cabinet. All cleaning supplies are locked and secured and inaccessible to residents. Fire extinguisher present with a purchase date of 12/02/2024. Outside of the facility toured, all exits open free of obstruction. Pool observed to be locked and secured and inaccessible to residents. There is outdoor seating and shade available for residents. All designated exits open free without obstruction. Due to time constraints LPA will return to review medication, staff and resident files and complete inspection tool. No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Oct 28, 2025

Type of visit: Office

On 08/5/2025, an informal office visit was held at the Fresno Regional Office. The purpose of the informal meeting was to discuss recently identified issues/concerns associated with the operation of the facility. The informal meeting process was explained during this meeting. The following were in attendance at this meeting: License, Linda Boden via telephone Administrator, Margaret Gardea Direct Care Staff, Alfredo Benavides Licensing Program Manager I, Sergiy Pidgirny Licensing Program Manager I, Alexandria Walton Licensing Program Analyst, Daiquiri Boyd Licensing Program Analyst, Melinda Medina During this meeting the following topics were discussed: - Staffing Concerns - Administrator Qualifications - Client Records - Food Service - Buildings and Grounds - Fingerprint Clearance - Accountability of licensee as a governing body The Licensee and Administrator were informed that continued non-compliance may necessitate the Department to seek Administrative Actions. The Licensee and Administrator were notified that the hospice wavier for the facility has been reduced to one (1) residents due to non-compliance. Exit interview conducted. A copy of this report provided to the Administrator during this meeting.the state’s words, verbatim · CDSS document, Aug 5, 2025

Type of visit: Case Management - Annual Continuation

On 9/0/24, Licensing Program Analysts (LPAs) M. Medina and S. Salazar conducted an unannounced Annual Required Continuation visit to facility. LPAs introduced self, stated purpose of visit and allowed entrance by Direct Care Staff. LPAs met with House Manager, Margaret Gardea to conduct visit. LPAs reviewed a sample of resident files including home health and Hospice care plans were observed. A sample of staff files were reviewed and observed to have the required documentation. LPAs interviewed staff and resident. Inspection tool completed. Exit interview conducted with Administrator. A copy of this report was provided at the time of visit. No deficiencies cited.the state’s words, verbatim · CDSS document, Sep 30, 2024

Type of visit: Required - 1 Year

On 9/25/24, Licensing Program Analysts (LPAs) M. Medina and L. Salazar conducted an unannounced Annual Required Inspection. LPAs arrived, introduced self, stated purpose of visit, and allowed entrance by Direct Care Staff. House Manager, Margaret Gardea contacted by telephone and arrived a short time later to conduct facility inspection. Facility tour conducted. Facility observed to be odor free, well lit, and a comfortable temperature. Facility tour began in kitchen. Facility observed to have a 2-day supply of perishable food and a 7-day of non-perishable food available. All kitchen dives observed to be locked and secured in the medication cabinet. Resident bedroom toured, all bedrooms observed to have required furnishings available. Resident bathrooms toured. Bathroom observed to have operational fixtures, shower/bathtub have shower chairs, grab bars, and non-skid mats available. Water temperature measured at 119 degrees F. Medications observed to be locked and secured in cabinet. Medications observed to have original labels and be administered as prescribed. All chemicals observed to be locked, secured, and inaccessible to residents. Fire extinguisher present with a purchase date of 12/18/2023. Carbon monoxide detector present and observed operational. Facility is equipped with a pull station. Outside of facility toured. Exit gate observed to be self-latching and observed free of obstruction. Pool is surrounded by 5 foot fence and observed to be locked, secured, and inaccessible to residents. Due to time constraints, inspection will be continued at a later date to review staff and resident files, as well as inspection tool. No deficiencies cited during inspection.the state’s words, verbatim · CDSS document, Sep 25, 2024

Type of visit: Case Management - Other

On 2/27/24, Licensing Program Analyst (LPA) M, Medina conducted an unannounced Case Management visit to facility. LPA introduced self, stated purpose of visit, and allowed entrance by direct care staff. LPA arrived to amend complaint findings to Complaint control 24-AS-2023102009474 dated 10/20/2023, and complaint findings delivered on 1/29/2024. LPA met with House Manager, Margaret Gardea to amend complaint report and deliver findings. Report signed at time of visit and copies provided for facility records.the state’s words, verbatim · CDSS document, Feb 27, 2024

Allegation investigated: Staff served residents expired food. Staff does not provide adequate amount of food for residents.

On 1/29/24, Licensing Program Analyst (LPA) M. Medina conducted an unannounced subsequent complaint visit to deliver findings. LPA introduced self, stated purpose of visit, and allowed entrance by staff. Administrator was not available to conduct today's visit. This department has investigated the above allegations. During facility tour and information obtained during interviews with staff and residents, the department has insufficient information regarding the above allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or disprove that the allegation occurred therefore the allegations are UNSUBSTANTIATED. Nothe state’s words, verbatim · CDSS document, Jan 29, 2024 · control 24-AS-20231213145616

Allegation investigated: Food service requirements are not being met Licensee does not ensure that staff receive medication training

On 1/29/24, Licensing Program Analyst (LPA) M. Medina conducted an unannounced subsequent complaint visit to deliver findings. LPA introduced self, stated purpose of visit, and allowed entrance by staff. Administrator was not available to conduct today's visit. This department has investigated the above allegation. During the course of the investigation, LPA toured the facility, conducted interviews, and reviewed documentation. Based on LPA observation of expired food in facility in both the pantry and refrigerator during facility tour on 12/14/2024. During record review, LPA observed documentation showing staff have insufficient hours of annual training for medication. The preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D. Exit interview conducted and a copy of this report was provided for facility records. Substantiatedthe state’s words, verbatim · CDSS document, Jan 29, 2024 · control 24-AS-20231020094747

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Feb 2, 2024

(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. ***This was not met as evidenced by during LPA tour of facility, LPA observed expired food in the refrigerator and pantry.the state’s words, verbatim · CDSS document, Jan 29, 2024

Plan of correction: Expired food was removed and thrown away during visit conducted on 12/14/24. Licensee to go through all food and remove expired food and ensure food is checked periodically to remove expired items. POC CLEARED AT TIME OF VISIT

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69(b) · Plan of correction due date: Mar 27, 2024

Employees assisting residents with self-administration of medication; training requirements (b)Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self- administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. ***This was not met as evidenced by during record reviewLPA observed documentation showing staff have insufficient hours of annual training for medication.the state’s words, verbatim · CDSS document, Jan 29, 2024

Plan of correction: Licensee/Administrator to conduct self audit and ensure that staff are receive minimum of 8 hours annual training in medication. Proof of correction and documentation to be submitted to Fresno Regional Office no later than POC due date.

Type of visit: Case Management - Health Checks

On 12/14/23, Licensing Program Analysts (LPA) M. Medina conducted a Case Management visit. LPA introduced self, stated purpose of visit and allowed entrance by Direct Care Staff. Direct Staff contacted Margaret Gardea and Diana Ellis by telephone who arrived a short time later. Licensee, Linda Boden contacted by telephone but did not answer. Facility tour conducted. Currently five residents in care. There are no residents on hospice, and one resident is currently receiving home health services. Outside of facility toured. Pool is surrounded by fence and observed to be locked and secured. All exits open free of obstruction. No hazards observed. No deficiencies observed or cited during visit.the state’s words, verbatim · CDSS document, Dec 14, 2023

Type of visit: Case Management - Health Checks

On 10/21/23, Licensing Program Analysts (LPA) M. Medina conducted a Case Management visit. LPA introduced self, stated purpose of visit and allowed entrance by Direct Care Staff. Direct Staff contacted Administrator, Diana Ellis and Licensee, Linda Boden by telephone who arrived a short time later to conduct facility visit. Facility tour conducted. Currently five residents in care. One resident is receiving hospice services and one resident is currently receiving treatment at Adventist Bakersfield Hospital. Outside of facility toured. Pool is surrounded by fence and observed to be locked and secured. All exits open free of obstruction. No hazards observed. No deficiencies observed or cited during visit.the state’s words, verbatim · CDSS document, Oct 21, 2023