The Terraces at San Joaquin Gardens Village
5551 N. Fresno St, Fresno, CA 93710 · Fresno County · 54 certified beds · avg 47 residents/day · certified since Nov 15, 1967
Part of chain: HUMANGOOD (17 facilities, chain avg rating 4.5★)
3/5
Health inspection rating (on-site)
1
Serious findings on record
$0
Fines, last 3 years
5.44
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 5/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, facility-wide · May 10, 2022 · F-0692
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (I): Residents were actually harmed and the failure existed throughout the facility. Rare and serious.
Corrected: Jun 9, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (31)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 23, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Mar 21, 2025 | F · Potential for harm, facility-wide | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Mar 21, 2025 | E · Potential for harm, repeated | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Mar 21, 2025 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Mar 21, 2025 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Mar 21, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Mar 21, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 21, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Mar 21, 2025 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Mar 21, 2025 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Mar 21, 2025 | D · Potential for harm, one-off | The facility did not provide routine dental care and 24-hour emergency dental care for residents. |
| Mar 21, 2025 | D · Potential for harm, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Sep 3, 2024 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Sep 3, 2024 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint |
| May 30, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Feb 12, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Feb 12, 2024 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Feb 12, 2024 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Feb 12, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 12, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 12, 2024 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Feb 12, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Feb 12, 2024 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| May 10, 2022 | ▲ I · Actual harm, facility-wide | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| May 10, 2022 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 10, 2022 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| May 10, 2022 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| May 10, 2022 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| May 10, 2022 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| May 10, 2022 | D · Potential for harm, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| May 10, 2022 | D · Potential for harm, one-off | The facility did not make sure its staff were vaccinated for COVID-19 in accordance with the federal requirements in effect at the time. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (8 → 11).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 8 | 1 | I ▲ |
| 2024 | 11 | 0 | E |
| 2025 | 12 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | California avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.44 | 4.31 | 3.95 | top 8% in California; top 8% in the U.S. |
| Registered Nurse hours | 1.08 | 0.61 | 0.69 | top 9% in California; top 13% in the U.S. |
| Weekend total nurse staffing | 4.72 | 3.90 | 3.50 | top 10% in California; top 9% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.80 | 0.51 | 0.48 | top 11% in California; top 11% in the U.S. |
| Total nursing staff turnover (%) | 30.3 | 36.7 | 45.8 | top 30% in California; top 15% in the U.S. |
| RN turnover (%) | 16.7 | 38.1 | 42.9 | top 13% in California; top 9% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.13, RN 1.02, weekend 4.45. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Humangood | Organization | 5% or Greater Indirect Ownership Interest | 100% | 05/01/2016 |
| Humangood Fresno | Organization | 5% or Greater Direct Ownership Interest | 100% | 08/01/2012 |
| Baker Tilly Advisory Group LP | Organization | ADP of the SNF | NOT APPLICABLE | 03/21/2025 |
| Baker Tilly Us LLP | Organization | ADP of the SNF | NOT APPLICABLE | 10/15/2024 |
| Baker, Judith | Individual | Corporate Director | NOT APPLICABLE | 04/25/2012 |
| Battison, William | Individual | Corporate Director | NOT APPLICABLE | 02/03/2011 |
| Brown, Herman | Individual | Corporate Director | NOT APPLICABLE | 05/01/2016 |
| Brown, Herman | Individual | Corporate Officer | NOT APPLICABLE | 05/01/2016 |
| Case, Alexis | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/21/2022 |
| Case, Alexis | Individual | ADP of the SNF | NOT APPLICABLE | 08/21/2022 |
| Chahal, Parmveer | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/04/2023 |
| Chahal, Parmveer | Individual | ADP of the SNF | NOT APPLICABLE | 01/04/2023 |
| Cochrane, John | Individual | Corporate Officer | NOT APPLICABLE | 08/10/2009 |
| Cochrane, John | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/10/2009 |
| Coleman, Esmeralda | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/02/2023 |
| Coleman, Esmeralda | Individual | ADP of the SNF | NOT APPLICABLE | 06/02/2023 |
| Dowell, Robert | Individual | Corporate Director | NOT APPLICABLE | 03/15/2024 |
| Ghassemi, Bethany | Individual | Corporate Officer | NOT APPLICABLE | 05/21/2019 |
| Ghassemi, Bethany | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/21/2019 |
| Griffith, Alan | Individual | Corporate Director | NOT APPLICABLE | 06/30/2019 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
- "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| North Point Healthcare & Wellness Centre LP | 0.3 mi | Fresno, CA | ★★★★★ | 5/5 | |
| Keystone Post-Acute | 2.4 mi | Fresno, CA | ★★☆☆☆ | 2/5 | |
| Horizon Health & Subacute Center | 2.6 mi | Fresno, CA | ★★☆☆☆ | 2/5 | |
| Oakwood Gardens Care Center | 2.7 mi | Fresno, CA | ★★★★★ | 4/5 | |
| Covenant Post Acute | 2.7 mi | Fresno, CA | ★★★☆☆ | 2/5 | |
| Community Subacute and Transitional Care Center | 2.8 mi | Fresno, CA | ★★★★★ | 5/5 | |
| Willow Creek Healthcare Center | 3.3 mi | Clovis, CA | ★★★☆☆ | 2/5 | |
| Morning Star Post Acute | 3.9 mi | Clovis, CA | ★★★☆☆ | 2/5 | |
| Healthcare Centre of Fresno | 5.3 mi | Fresno, CA | ★★☆☆☆ | 2/5 | |
| Orchard Post Acute | 5.9 mi | Fresno, CA | ★★★☆☆ | 2/5 | |
| Fresno Postacute Care | 6.3 mi | Fresno, CA | ★★★☆☆ | 3/5 | |
| Evergreen Care Center | 6.4 mi | Fresno, CA | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 055846.