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Nursing HomeMedicaid

Pacific Gardens Nursing and Rehabilitation Center

Meets baseline Medicare standards with room for improvement. A tour and talking to current residents' families is the best next step.

577 S. Peach Ave., Roosevelt · Fresno, CA 93727188 bedsLicensed & Active
3/5
Medicare
Inspection
Quality
Staffing
Google rating
4.4/5

based on 40 Google reviews

5
4
3
2
1

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What this means for your family

The facility excels in providing emotionally supportive and kind bedside care from its nursing and CNA teams. However, families must remain vigilant regarding medical monitoring and staffing levels, as some reviewers have reported issues with neglected medical needs and slow response times.

Google Reviews

Google Reviews

40 reviews on Google
Families can expect highly compassionate and dedicated nursing and CNA staff, with many reviewers praising specific individuals for their kindness and professionalism. However, there are serious concerns regarding understaffing, inconsistent rehabilitation therapy, and instances of inadequate medical monitoring.

Quality Themes

FoodN/AStaff9.0Clean8.0Activities6.0Meds4.0MemoryN/AComms3.0ValueN/A

Strengths

  • Compassionate and attentive nursing/CNA staff
  • Clean and well-maintained environment
  • Professional wound care services
  • Friendly and helpful housekeeping

Concerns

  • Understaffing leading to slow response times (mentioned by 2 reviewers)
  • Inconsistency in rehabilitation therapy staff and scheduling
  • Lack of communication with families

Rating Trends

Tap a year to see what changed

2342.32025(3)4.62026(40)

Distribution · 43 analyzed

5
34
4
3
3
2
2
0
1
4
19 reviews posted between Mar 25, 2026Apr 3, 2026 · 15 were 5-star

How They Respond to Reviews

80%response rate
Good

The owner provides personalized responses that specifically mention the names of staff members and the specific care qualities highlighted by the reviewer. The tone is consistently warm, professional, and appreciative.

Questions for Your Tour

  • 1I noticed some families have shared how much they appreciate the compassionate nursing and housekeeping staff; how do you ensure that level of care remains consistent for every resident?
  • 2With the recent state inspections, what specific steps is the facility taking to address the identified deficiencies and improve overall care quality?
  • 3How does the facility manage medication administration to ensure there are no errors or delays in the daily routine?
  • 4Can you tell me more about how the nursing and therapy teams communicate with families regarding a resident's progress or any changes in their condition?
  • 5What is the protocol for handling medical emergencies or urgent care needs during the night or over the weekend?
  • 6What kind of daily activities or social engagement programs are available to help residents stay active and connected with others?

Personalized based on this facility's data


Key Review Excerpts

My father spent about 3 months at this facility after breaking his hip/femur. Overall, the staff did a good job providing care even when he was disoriented and not particularly cooperative; someone was always watching at the nurses' station when he couldn't stay in his bed alone.

Rehab patient's family · 2026★★★★

I was a state surveyor for over 20+ years and I have NEVER seen such stellar work, esp. on the MEDICARE SIDE where I’ve been a patient after brain surgery.

Former state surveyor and patient · 2026★★★★★

My mother was at this facility for several weeks. As others have stated, this place is understaffed. They don't appear to care very much about patients. My mother's blood sugar was extremely elevated, and not being addressed; which resulted in health conditions that she did not previously have.

Long-term resident's family · 2026☆☆☆☆
Source: 40 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.68hrs
91%
Registered nurses for medical care
Total Nursing
4.11hrs
OK
All nurses + aides combined

RN hours are below the national benchmark. RNs handle complex medical needs and medication, so ask about coverage during your visit.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
5/ 5
Better Than Avg

11

measures

Mixed Results

6

measures

Long-Stay Residents
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility5.3%
Better than Avg
Here
5.3%
US
19.4%
CA
10.7%
Fresno
12.6%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility8.2%
Better than Avg
Here
8.2%
US
19.5%
CA
13.7%
Fresno
16.2%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility5.6%
Better than Avg
Here
5.6%
US
15.4%
CA
11.6%
Fresno
9.2%
😔

Residents with depression symptoms

↓ Lower is better
This Facility3.1%
Better than Avg
Here
3.1%
US
12.1%
CA
7.0%
Fresno
5.1%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility5.8%
Better than Avg
Here
5.8%
US
14.4%
CA
10.4%
Fresno
11.1%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility99.8%
Better than Avg
Here
99.8%
US
93.4%
CA
98.6%
Fresno
98.4%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility91.1%
Mixed vs Avgs
Here
91.1%
US
79.7%
CA
93.2%
Fresno
93.8%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility90.7%
Mixed vs Avgs
Here
90.7%
US
81.8%
CA
94.2%
Fresno
94.3%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility1.0%
Mixed vs Avgs
Here
1.0%
US
1.6%
CA
1.5%
Fresno
0.6%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

20deficiencies
1penalties
Above state avg (15.4)
7 complaint-triggered
$30,654 in fines

This facility shows concerning patterns with families filing 7 complaints over recent years about serious issues including pressure ulcer care, food safety, and pest control. The main recurring problems are in resident rights, fire safety systems, and care planning, with many deficiencies appearing repeatedly across multiple surveys, suggesting ongoing challenges with maintaining standards. While all violations have correction plans, the frequency of complaints and repeat deficiencies should prompt careful evaluation during any visit.

Aug 27, 2025Complaint
1
0621Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Treat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment source

Feb 7, 2025Routine
23
0688Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

0293Potential for harm · WidespreadCorrected

Egress Deficiencies

Have properly located and lighted "Exit" signs.

0345Potential for harm · WidespreadCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0578Potential for harm · PatternCorrected

Resident Rights Deficiencies

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.

0584Potential for harm · PatternCorrected

Resident Rights Deficiencies

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.

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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.

0802Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0924Potential for harm · PatternCorrected

Environmental Deficiencies

Put firmly secured handrails on each side of hallways.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0625Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0687Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate foot care.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0732Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

0757Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

0760Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

0761Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

0353Minimal · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Nov 26, 2024Complaint
2
0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0726Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

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.

Oct 4, 2024Complaint
2
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0925Potential for harm · WidespreadCorrected

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Mar 15, 2024Complaint
1
0686Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Nov 30, 2023Routine
13
0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0695Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0554Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

0584Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

0293Potential for harm · IsolatedCorrected

Egress Deficiencies

Have properly located and lighted "Exit" signs.

0324Potential for harm · IsolatedCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0355Potential for harm · IsolatedCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

0363Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0781Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

Have restrictions on the use of portable space heaters.

0919Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the use of electrical equipment.

0920Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Federal Penalties

Fine

Feb 7, 2025

$30,654

Ownership & Operations

Who Operates This Facility

Owner / Operator

Pacific Gardens Nursing and Rehabilitation Center

Organization Type

for profit

Chain Affiliation

Chain Name

Covenant Care

Chain Size

19 facilities nationwide

Chain avg rating: 2.8/5 · Rank 12 of 24

Ownership & Management

Owners

Covenant Care California, LLC

Owner · Organization

Covenant Care, LLC

Owner · Organization

Centre Capital Investors V, Lp

Owner (parent company) · Organization

Centre Covenant Purchaser (b), LLC

Owner (parent company) · Organization

Centre Covenant Purchaser (q), LLC

Owner (parent company) · Organization

Centre Covenant Purchaser (s), LLC

Owner (parent company) · Organization

Centre V Secondary Fund, L.p.

Owner (parent company) · Organization

Covenant Holdco, LLC

Owner (parent company) · Organization

Covenant Subco, LLC

Owner (parent company) · Organization

State Treasurer of Mich Custodian of Public School Empl Rtmnt Systems

Owner (parent company) · Organization

Stockwell Fund II Lp

Owner (parent company) · Organization

Evans, Mary

Owner (parent company)

Levin, Robert

Owner (parent company)

Sims, Christine

Owner (parent company)

Torok, Andrew

Owner (parent company)

Key personnel

Midcap Funding IV Trust5% or Greater Security InterestAshley, DavaOfficer / DirectorCarney, KevinOfficer / DirectorEvans, MaryOfficer / DirectorHassell, LanceOfficer / Director
Source: Medicare provider data

Contact

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References & Resources

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