Federal inspection record · CMS data as of October 1, 2026
Pacific Gardens Nursing And Rehabilitation Center
577 S. Peach Ave., Fresno, CA · (559) 251-8463
- Certified beds
- 188
- Residents per day
- 162
- Ownership
- For-Profit
- Chain
- The Ensign Group
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- July 6, 1970
1
How this home got 3 stars
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
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
★★★★★+1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★3 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among California homes
Pacific Gardens Nursing And Rehabilitation Center carries 119 inspection points. That is fewer than 30% 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
48 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 (2)
-
G
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Everything else, by area of care
Resident Rights9E
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
- D
Treat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment source
- E
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Assessment and Care Planning8E
- E
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- 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
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Pharmacy Service8E
- E
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 medication error rates are not 5 percent or greater.
- 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
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.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
Ensure that residents are free from significant medication errors.
Nutrition and Dietary7F
- E
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.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- D
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
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.
Quality of Life and Care7E
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
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.
- D
Provide appropriate foot care.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- E
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide enough food/fluids to maintain a resident's health.
Infection Control2E
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
Environmental2F
- E
Put firmly secured handrails on each side of hallways.
- F
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Nursing and Physician Services2D
- D
Post nurse staffing information every day.
- 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.
Freedom from Abuse, Neglect, and Exploitation1D
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspection history
2026-04-24
19 health deficiencies · 10 fire-safety deficiencies
Top issue: Pharmacy Service (5 deficiencies)
2025-02-07
24 health deficiencies · 4 fire-safety deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
2023-11-30
5 health deficiencies · 9 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 5 min of nursing staff time a day, 41 min of it from a registered nurse.
This home
4 h 5 min
California average
4 h 33 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 37% of nursing staff and 49% of registered nurses left in the past year, along with 1 administrator.
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
$30,654 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-02-07 | Fine | $30,654 |
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 days0.6 pts better | 1.6 | 2.2 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.5 pts better | 1.0 | 1.5 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine0.9 pts better | 99.6% | 98.7% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine2.1 pts better | 100.0% | 97.9% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.2 pts worse | 1.8% | 1.6% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms5.7 pts better | 1.9% | 7.6% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.5 pts worse | 5.6% | 4.1% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication6 pts better | 7.7% | 13.7% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication6.8 pts better | 5.5% | 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 worsened2.2 pts worse | 11.1% | 8.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased3.5 pts better | 6.7% | 10.2% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladderAbout the same | 0.7% | 0.7% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.5 pts better | 0.7% | 1.2% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence4.2 pts better | 5.6% | 9.8% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.7 pts worse | 5.0% | 4.3% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine3.9 pts worse | 90.7% | 94.6% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit0.5 pts better | 10.6% | 11.1% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.3 pts better | 1.0% | 1.3% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine1.3 pts worse | 91.8% | 93.1% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission0.6 pts better | 22.0% | 22.6% | 23.4% |
·
Who owns and runs it
13 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 |
|---|---|---|---|
| Burnam, Soon | Corporate Officer · Individual | 0% | 353 facilities |
| Chandar, John | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Chandar, John | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Chandar, John | Adp Of The SNF · Individual | 0% | 1 facilities |
| Ensign Services Inc | Adp Of The SNF · Organization | 0% | 299 facilities |
| Keetch, Chad | Corporate Officer · Individual | 0% | 301 facilities |
| Malley, Roman | Managing Control - Governing Body · Individual | 0% | 2 facilities |
| Malley, Roman | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Malley, Roman | Adp Of The SNF · Individual | 0% | 2 facilities |
| Monette, Cory | Corporate Officer · Individual | 0% | 10 facilities |
| Port, Barry | Corporate Director · Individual | 0% | 203 facilities |
| Sato, Ami | Corporate Officer · Individual | 0% | 151 facilities |
| Willits, Adam | Corporate Officer · Individual | 0% | 77 facilities |
·
Fire safety
23 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke12F
- F
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Install corridor and hallway doors that block smoke.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- C
Properly install and monitor supervisory attachments on automatic sprinkler systems.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- C
Inspect, test, and maintain automatic sprinkler systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- D
Provide properly protected cooking facilities.
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
- D
Install corridor and hallway doors that block smoke.
Gas, Vacuum, and Electrical Systems5F
- E
Have proper medical gas storage and administration areas.
- C
Have generator or other power source capable of supplying service within 10 seconds.
- 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.
Egress3F
- F
Have properly located and lighted "Exit" signs.
- F
Have properly located and lighted "Exit" signs.
- D
Have properly located and lighted "Exit" signs.
Miscellaneous3D
- D
Have restrictions on the use of portable space heaters.
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- D
Have restrictions on the use of portable space heaters.
·
Other homes nearby
-
Evergreen Care Center
Fresno, CA · Ajc Healthcare
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 4 h 29 min
- Fines
- $0
-
Orchard Post Acute
Fresno, CA · Pacs Group
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 4 h
- Fines
- $0
-
Stonehaven Senior Living
Fresno, CA · Jericho Care Group
Not rated- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 4 h 4 min
- Fines
- $0