Pacific Gardens Nursing and Rehabilitation Center
577 S. Peach Ave., Fresno, CA 93727
Pacific Gardens Nursing and Rehabilitation Center is a nursing home in Fresno, California. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating3 of 5
- Last standard health inspectionApril 24, 2026 (6 months ago)
- Health citations since November 30, 202348 (California average 50)
- Fines in the past three years1, $30,654 in total
- CMS flagsNone listed by CMS
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One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Name
CMS lists a new legal business name for this home.
Ownership
CMS lists this home under a new chain.
Ownership
CMS ownership records list new owners for this home.
CMS update of July 29, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 4 of 5.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Health inspection on April 24, 2026
18 citationsCMS lists this as a standard inspection.
Show the 18 citations
Citation F0658. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on May 15, 2026.
CMS has cited this home for F0658 4 times since 2024.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on May 15, 2026.
Citation F0757. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on May 15, 2026.
CMS has cited this home for F0757 2 times since 2025.
Citation F0759. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on May 15, 2026.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 15, 2026.
CMS has cited this home for F0761 2 times since 2025.
Citation F0803. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 15, 2026.
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on May 15, 2026.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on May 15, 2026.
CMS has cited this home for F0554 2 times since 2023.
Citation F0605. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS lists it as corrected on May 15, 2026.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on May 15, 2026.
CMS has cited this home for F0656 2 times since 2025.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on May 15, 2026.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on May 15, 2026.
CMS has cited this home for F0692 2 times since 2023.
Citation F0700. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 15, 2026.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on May 15, 2026.
CMS has cited this home for F0760 2 times since 2025.
Citation F0805. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
CMS lists it as corrected on May 15, 2026.
Citation F0806. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS lists it as corrected on May 15, 2026.
Citation F0812. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on May 15, 2026.
CMS has cited this home for F0812 3 times since 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 15, 2026.
CMS has cited this home for F0880 2 times since 2025.
Fire safety inspection on April 24, 2026
10 citationsCMS lists this as a standard inspection.
Show the 10 citations
Citation K0293. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on April 29, 2026.
CMS has cited this home for K0293 3 times since 2023.
Citation K0342. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
CMS lists it as corrected on May 5, 2026.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on April 30, 2026.
CMS has cited this home for K0345 2 times since 2025.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on May 1, 2026.
CMS has cited this home for K0353 3 times since 2023.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on April 28, 2026.
CMS has cited this home for K0363 2 times since 2023.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on May 5, 2026.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on May 5, 2026.
Citation K0781. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have restrictions on the use of portable space heaters.
CMS lists it as corrected on April 28, 2026.
CMS has cited this home for K0781 2 times since 2023.
Citation K0352. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Properly install and monitor supervisory attachments on automatic sprinkler systems.
CMS lists it as corrected on April 30, 2026.
Citation K0918. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on May 7, 2026.
CMS has cited this home for K0918 2 times since 2023.
Health inspection on April 1, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on April 3, 2026.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 1 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.0 to 2.9 hours per resident per day.
Health citation
CMS changed citation F0550 from severity E to D. It is from the health inspection on February 7, 2025. Severity D: potential for more than minimal harm, isolated.
Health citation
CMS changed citation F0658 from severity E to D. It is from the health inspection on February 7, 2025. Severity D: potential for more than minimal harm, isolated.
Health citation
CMS changed citation F0732 from severity F to D. It is from the health inspection on February 7, 2025. Severity D: potential for more than minimal harm, isolated.
Health citation
CMS changed citation F0842 from severity E to D. It is from the health inspection on February 7, 2025. Severity D: potential for more than minimal harm, isolated.
Health citation
CMS changed citation F0658 from severity E to D. It is from the health inspection on November 26, 2024. Severity D: potential for more than minimal harm, isolated.
Health citation
CMS changed citation F0726 from severity E to D. It is from the health inspection on November 26, 2024. Severity D: potential for more than minimal harm, isolated.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
Health citation
CMS changed citation F0658 from severity D to E. It is from the health inspection on November 26, 2024. Severity E: potential for more than minimal harm, pattern.
Health citation
CMS changed citation F0726 from severity D to E. It is from the health inspection on November 26, 2024. Severity E: potential for more than minimal harm, pattern.
Health citation
CMS changed citation F0550 from severity D to E. It is from the health inspection on February 7, 2025. Severity E: potential for more than minimal harm, pattern.
Health citation
CMS changed citation F0658 from severity D to E. It is from the health inspection on February 7, 2025. Severity E: potential for more than minimal harm, pattern.
Health citation
CMS changed citation F0732 from severity D to F. It is from the health inspection on February 7, 2025. Severity F: potential for more than minimal harm, widespread.
Health citation
CMS changed citation F0842 from severity D to E. It is from the health inspection on February 7, 2025. Severity E: potential for more than minimal harm, pattern.
Health inspection on August 27, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0621. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Treat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment source
CMS lists it as corrected on October 1, 2025.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
Fine
CMS changed the fine from February 7, 2025 from $47,160 to $30,654.
CMS update of June 25, 2025
Health citation
CMS removed citation F0625 from the health inspection on February 7, 2025.
CMS update of May 28, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 3 of 5.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Health citation
CMS changed citation F0658 from severity E to D. It is from the health inspection on November 26, 2024. Severity D: potential for more than minimal harm, isolated.
Health citation
CMS changed citation F0726 from severity E to D. It is from the health inspection on November 26, 2024. Severity D: potential for more than minimal harm, isolated.
Health inspection on February 7, 2025
19 citationsCMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
227 of 1,165 California homes (19%) got a citation at the actual harm level in 2025.
CMS fine of $30,654 on February 7, 2025.
Show the 19 citations
Citation F0688. Severity G: actual harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 11, 2025.
Citation F0578. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on March 11, 2025.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on March 11, 2025.
CMS has cited this home for F0584 2 times since 2023.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on March 11, 2025.
Citation F0802. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
CMS lists it as corrected on March 11, 2025.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on March 11, 2025.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on March 11, 2025.
Citation F0924. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Put firmly secured handrails on each side of hallways.
CMS lists it as corrected on March 11, 2025.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on March 11, 2025.
Citation F0625. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 11, 2025.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on March 11, 2025.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on March 11, 2025.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on March 11, 2025.
Citation F0687. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate foot care.
CMS lists it as corrected on March 11, 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on March 11, 2025.
Citation F0732. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on March 11, 2025.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on March 11, 2025.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on March 11, 2025.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on March 11, 2025.
Fire safety inspection on February 7, 2025
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation K0293. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on February 13, 2025.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on February 27, 2025.
Citation K0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on February 14, 2025.
Citation K0353. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on February 14, 2025.
Health inspection on November 26, 2024
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
The home is disputing this citation through CMS's informal review.
CMS lists it as corrected on December 29, 2024.
Citation F0726. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
The home is disputing this citation through CMS's informal review.
CMS lists it as corrected on December 29, 2024.
Health inspection on October 4, 2024
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on November 1, 2024.
Citation F0925. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on November 1, 2024.
Health inspection on March 15, 2024
1 citationCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
256 of 1,165 California homes (22%) got a citation at the actual harm level in 2024.
Show the 1 citation
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on April 1, 2024.
CMS update of February 29, 2024
Fine
CMS changed the fine from September 23, 2021 from $5,735 to $3,728.
Fine
CMS changed the fine from December 20, 2022 from $15,000 to $9,750.
Health inspection on November 30, 2023
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation F0695. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on December 28, 2023.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on December 28, 2023.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 28, 2023.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on December 28, 2023.
Fire safety inspection on November 30, 2023
9 citationsCMS lists this as a standard inspection.
Show the 9 citations
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on December 30, 2023.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on December 30, 2023.
Citation K0293. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on December 30, 2023.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on December 30, 2023.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on December 30, 2023.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on December 30, 2023.
Citation K0781. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have restrictions on the use of portable space heaters.
CMS lists it as corrected on December 30, 2023.
Citation K0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on December 30, 2023.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on December 30, 2023.
CMS star ratings
- 3 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (559) 251-8463
- Last standard health inspection
- April 24, 2026 (6 months ago)
- Certified beds
- 188
- Residents per day, on average
- 162.3
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Juniper Springs Healthcare INC
- Chain
- The Ensign Group
- Takes part in
- Medicare and Medicaid
Fewer health citations than the California average (48 vs 50).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- CHANDAR, JOHNOperational/managerial control · not applicable · since 08/01/2025
- MALLEY, ROMANOperational/managerial control · not applicable · since 08/01/2025
Questions
When was Pacific Gardens Nursing and Rehabilitation Center last inspected?
CMS lists April 24, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Pacific Gardens Nursing and Rehabilitation Center have?
CMS lists 48 health citations since November 30, 2023. CMS also calls these deficiencies.
Has Pacific Gardens Nursing and Rehabilitation Center been fined?
CMS lists 1 fine in the past three years, $30,654 in total.
What is the CMS star rating of Pacific Gardens Nursing and Rehabilitation Center?
Its CMS overall star rating is 3 of 5.
Is Pacific Gardens Nursing and Rehabilitation Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.