Federal inspection record · CMS data as of October 1, 2026
Grace Healthcare Center
2939 S. Peach Avenue, Fresno, CA · (559) 233-6248
- Certified beds
- 101
- Residents per day
- 60
- Ownership
- For-Profit
- Chain
- No chain reported
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- June 1, 1989
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
-
Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in California.
-
Staffing
★★★★★no change (already 1)
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among California homes
Grace Healthcare Center carries 190 inspection points. That is fewer than 10% of California's 1,154 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in California: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–33 pts
- 4★ 33–66 pts
- 3★ 66–96 pts
- 2★ 96–146 pts
- 1★ over 146 pts
Bars show every rated home in California by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
74 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Everything else, by area of care
Resident Assessment and Care Planning17F
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Ensure each resident receives an accurate assessment.
- D
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- F
Ensure each resident receives an accurate assessment.
- E
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- E
Assure that each resident’s assessment is updated at least once every 3 months.
- E
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Nutrition and Dietary10F
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
- F
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- E
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- D
Dispose of garbage and refuse properly.
Pharmacy Service9F
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- F
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Ensure medication error rates are not 5 percent or greater.
- E
Ensure that residents are free from significant medication errors.
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Infection Control7F
- F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
- E
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- D
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
- F
Provide and implement an infection prevention and control program.
- F
Provide and implement an infection prevention and control program.
Environmental7F
- F
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
- E
Have policies on smoking.
- F
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- D
Keep all essential equipment working safely.
- C
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- B
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Quality of Life and Care6E
- E
Provide enough food/fluids to maintain a resident's health.
- E
Provide enough food/fluids to maintain a resident's health.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- E
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
- D
Provide enough food/fluids to maintain a resident's health.
Nursing and Physician Services5F
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
- D
Observe each nurse aide's job performance and give regular training.
- D
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
- D
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Resident Rights5D
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- D
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Freedom from Abuse, Neglect, and Exploitation4F
- F
Protect each resident from the wrongful use of the resident's belongings or money.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Administration3E
- E
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
- E
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
- E
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Inspection history
2026-03-20
24 health deficiencies · 14 fire-safety deficiencies
Top issue: Resident Assessment and Care Planning (8 deficiencies)
2024-09-13
28 health deficiencies · 8 fire-safety deficiencies
Top issue: Pharmacy Service (4 deficiencies)
2023-06-16
22 health deficiencies · 21 fire-safety deficiencies
Top issue: Nutrition and Dietary (5 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 2 h 28 min of nursing staff time a day, 17 min of it from a registered nurse.
This home
2 h 28 min
California average
4 h 33 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 51% of nursing staff and 50% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$0 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-09-05 | Payment Denial · 4 day denial | $0 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days3.2 pts worse | 5.4 | 2.2 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days3.7 pts worse | 5.2 | 1.5 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine0.4 pts better | 99.1% | 98.7% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine0.5 pts better | 98.4% | 97.9% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury2.7 pts worse | 4.3% | 1.6% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms5.8 pts worse | 13.4% | 7.6% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.1 pts worse | 5.2% | 4.1% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication15.3 pts worse | 29.0% | 13.7% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication4.1 pts worse | 16.4% | 12.3% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.3 pts better | 0.0% | 0.3% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened4.8 pts better | 4.1% | 8.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased4.4 pts better | 5.8% | 10.2% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder1.1 pts worse | 1.8% | 0.7% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.1 pts worse | 1.3% | 1.2% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence5.4 pts worse | 15.2% | 9.8% | 18.3% |
| Percentage of long-stay residents with pressure ulcers2.3 pts worse | 6.6% | 4.3% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine17.9 pts worse | 76.7% | 94.6% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit25 pts worse | 36.1% | 11.1% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.3 pts better | 0.0% | 1.3% | 1.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission19.7 pts worse | 42.3% | 22.6% | 23.4% |
·
Who owns and runs it
4 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Gonzalez, Llatisha | 5% Or Greater Direct Ownership Interest · Individual | 100% | 1 facilities |
| Gonzalez, Llatisha | W-2 Managing Employee · Individual | 0% | 1 facilities |
| Gonzalez, Llatisha | Corporate Director · Individual | 0% | 1 facilities |
| Gonzalez, Llatisha | Corporate Officer · Individual | 0% | 1 facilities |
·
Fire safety
43 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke15F
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D
Install corridor and hallway doors that block smoke.
- C
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- C
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Install corridor and hallway doors that block smoke.
- D
Provide properly protected cooking facilities.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Properly provide smoke detection systems in areas open to corridors.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D
Provide properly protected cooking facilities.
- D
Install corridor and hallway doors that block smoke.
Gas, Vacuum, and Electrical Systems12F
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- D
Meet requirements for the use of electrical equipment.
- D
Ensure proper usage of power strips and extension cords.
- D
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- D
Ensure proper usage of power strips and extension cords.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- F
Ensure proper usage of power strips and extension cords.
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- D
Have proper medical gas storage and administration areas.
- C
Meet requirements for the use of electrical equipment.
Emergency Preparedness8F
- F
Conduct testing and exercise requirements.
- E
Implement emergency and standby power systems.
- D
Conduct testing and exercise requirements.
- D
Conduct risk assessment and an All-Hazards approach.
- C
Establish policies and procedures including evacuation.
- C
List the names and contact information of those in the facility.
- C
Provide emergency officials' contact information.
- C
Address patient/client population and determine types of services needed.
Egress4F
- F
Have properly located and lighted "Exit" signs.
- F
Have properly located and lighted "Exit" signs.
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- E
Have properly located and lighted "Exit" signs.
Miscellaneous2F
- F
Have simulated fire drills held at unexpected times.
- E
Have simulated fire drills held at unexpected times.
Services2F
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- D
Meet other general requirements that are deficient.
·
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Sierra Vista Healthcare
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-
Pacific Gardens Nursing And Rehabilitation Center
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