Map showing the location of GRACE HEALTHCARE CENTER in FRESNO, California
2939 S. PEACH AVENUE, FRESNO, CA, 93725

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • CaliforniaLowest tier among peers1,154 rated homes · average 3.2★
  • Fresno CountyLowest tier among peers30 rated homes · average 3.0★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.8 vs CA avg
  • StaffingCan add or remove a star4★+0.9 vs CA avg
  • Quality measuresCan add or remove a star4★−0.1 vs CA avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

  • Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersCA avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover4★Above 60% of peersCA avg3.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above only 24% of peersCA avg4.1★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff4.52hrsAbove 69% of peersCA avg4.51Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.79hrsAbove 81% of peersCA avg0.65Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better37%Above 52% of peersCA avg38%RN turnover13%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$50,106Above only 17% of peersCA avg$26,970Fines · denials7 · 2
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
70citations
12inspection dates
1actual harm (G–I)
0immediate jeopardy (J–L)
Sep 5, 2025most recent

Citations by monthOct 2019 – Sep 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Sep 5, 20251 citationCycle 1worst G · actual harmpayment denial
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Oct 15, 2025
Dec 23, 20241 citationCycle 2worst D · no actual harm
  1. F727Have 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.Nursing and Physician ServicesD · isolatedCorrected Jan 23, 2025
Oct 2, 20249 citationsCycle 2worst F · no actual harm
  1. Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.AdministrationE · patternCorrected Nov 15, 2024
  2. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceE · patternCorrected Nov 15, 2024
  3. F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.AdministrationE · patternCorrected Nov 15, 2024
  4. F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Infection ControlD · isolatedCorrected Nov 15, 2024
  5. F602Protect each resident from the wrongful use of the resident's belongings or money.Freedom from Abuse, Neglect, and ExploitationF · widespreadCorrected Nov 15, 2024
  6. F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 15, 2024
  7. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceF · widespreadCorrected Nov 15, 2024
  8. F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.AdministrationE · patternCorrected Nov 15, 2024
  9. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Nov 15, 2024
Sep 13, 202417 citationsCycle 1worst F · no actual harm
  1. F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningD · isolatedCorrected Oct 15, 2024
  2. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Oct 15, 2024
  3. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Oct 15, 2024
  4. F700Try 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.Quality of Life and CareD · isolatedCorrected Oct 15, 2024
  5. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Oct 15, 2024
  6. F761Ensure 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.Pharmacy ServiceE · patternCorrected Oct 15, 2024
  7. F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Nutrition and DietaryF · widespreadCorrected Oct 15, 2024
  8. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Oct 15, 2024
  9. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Oct 15, 2024
  10. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Oct 15, 2024
  11. Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care PlanningD · isolatedCorrected Oct 15, 2024
  12. F803Ensure 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.Nutrition and DietaryF · widespreadCorrected Oct 15, 2024
  13. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Oct 15, 2024
  14. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Oct 15, 2024
  15. F908Keep all essential equipment working safely.EnvironmentalD · isolatedCorrected Oct 15, 2024
  16. F911Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.EnvironmentalC · widespreadCorrected Oct 15, 2024
  17. F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalF · widespreadCorrected Oct 15, 2024
May 16, 20241 citationCycle 2worst D · no actual harm
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 4, 2024
Jan 4, 20241 citationCycle 3worst D · no actual harm
  1. F573Let each resident or the resident's legal representative access or purchase copies of all the resident's records.Resident RightsD · isolatedCorrected Mar 1, 2024
Aug 22, 20232 citationsCycle 3worst E · no actual harm$4,587, $4,587, $4,587
  1. F584Honor 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 RightsE · patternCorrected Sep 5, 2023
  2. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Sep 5, 2023
Jun 16, 202320 citationsCycle 2worst F · no actual harm$4,587
  1. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryE · patternCorrected Aug 1, 2023
  2. Assure that each resident’s assessment is updated at least once every 3 months.Resident Assessment and Care PlanningE · patternCorrected Aug 1, 2023
  3. Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care PlanningE · patternCorrected Aug 1, 2023
  4. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected Aug 1, 2023
  5. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningF · widespreadCorrected Aug 1, 2023
  6. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Aug 1, 2023
  7. F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningE · patternCorrected Aug 1, 2023
  8. F700Try 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.Quality of Life and CareE · patternCorrected Aug 1, 2023
  9. F727Have 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.Nursing and Physician ServicesD · isolatedCorrected Aug 1, 2023
  10. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Aug 1, 2023
  11. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceE · patternCorrected Aug 1, 2023
  12. F761Ensure 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.Pharmacy ServiceE · patternCorrected Aug 1, 2023
  13. F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Nutrition and DietaryE · patternCorrected Aug 1, 2023
  14. F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and DietaryE · patternCorrected Aug 1, 2023
  15. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Aug 1, 2023
  16. F814Dispose of garbage and refuse properly.Nutrition and DietaryD · isolatedCorrected Aug 1, 2023
  17. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Aug 1, 2023
  18. F911Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.EnvironmentalB · patternCorrected Aug 1, 2023
  19. F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalD · isolatedCorrected Aug 1, 2023
  20. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Aug 1, 2023
May 30, 20232 citationsCycle 3worst F · no actual harmpayment denial, $13,409
  1. F836Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.AdministrationF · widespreadCorrected Jul 14, 2023
  2. F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningD · isolatedCorrected Jul 14, 2023
Apr 5, 20232 citationsCycle 3worst F · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected Apr 16, 2023
  2. F727Have 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.Nursing and Physician ServicesF · widespreadCorrected Apr 16, 2023
Mar 16, 20233 citationsCycle 3worst E · no actual harm
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceE · patternCorrected Apr 5, 2023
  2. F727Have 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.Nursing and Physician ServicesE · patternCorrected Apr 5, 2023
  3. F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.AdministrationE · patternCorrected Apr 5, 2023
Oct 31, 201911 citationsCycle 3worst F · no actual harm
  1. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Feb 21, 2020
  2. F814Dispose of garbage and refuse properly.Nutrition and DietaryF · widespreadCorrected Feb 21, 2020
  3. F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.AdministrationF · widespreadCorrected Feb 21, 2020
  4. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Feb 21, 2020
  5. F911Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.EnvironmentalB · patternCorrected Feb 21, 2020
  6. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Feb 21, 2020
  7. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Feb 21, 2020
  8. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Feb 21, 2020
  9. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Feb 21, 2020
  10. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Feb 21, 2020
  11. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryE · patternCorrected Feb 21, 2020

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined4.52hrsAbove 69% of peers+0.01 vs CA avg
  • Registered nursesRN hours only0.79hrsAbove 81% of peers+0.14 vs CA avg
  • Licensed practical nursesLPN hours0.71hrs
  • Nurse aidesCNA hours3.03hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.87hrs
  • California average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better37%Above 52% of peersCA avg 38%
  • RN turnoverRegistered nurses only13%Not ranked by CMS
  • Administrators who leftIn the past year2Leadership changed
  • Occupancy99 certified beds · ~59 residents a day60%Above only 4% of peersCA avg 88%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $50,106In fines
  • 7Fines
  • 2Payment denials
  • $26,970CA avg in fines
Above only 17% of peersFewer fines than 17% of rated homes in California

Actions on record

  1. Sep 5, 2025Denial of payment for new admissionsfrom Oct 11, 2025
  2. Sep 5, 2023Civil money penalty$4,587
  3. Aug 28, 2023Civil money penalty$4,587
  4. Aug 21, 2023Civil money penalty$4,587
  5. Aug 14, 2023Civil money penalty$4,587
  6. Jul 17, 2023Civil money penalty$13,762
  7. Jun 26, 2023Civil money penalty$4,587
  8. May 30, 2023Denial of payment for new admissionsfrom Aug 30, 2023
  9. May 15, 2023Civil money penalty$13,409

Ownership

As filed with CMS

Structure

Ownership type
For profit - Partnership
Chain
Independent
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Llatisha Gonzalez
Corporate directors
  • Llatisha Gonzalez
Corporate officers
  • Llatisha Gonzalez
Managing employees
  • Llatisha Gonzalez

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 555352 · 2939 S. PEACH AVENUE, FRESNO, CA, 93725.
  • Percentiles compare this facility with every rated nursing home in California and Fresno County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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