Healthcare Facility Inspection of the VA Central California Health Care System in Fresno

View Report

Date Issued

Thursday, February 12, 2026

Submitting OIG

Department of Veterans Affairs OIG

Agencies Reviewed/Investigated

Department of Veterans Affairs

Components

Veterans Health Administration

Report Number

25-00214-61

Report Description

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the Healthcare Facility Inspection of the VA Central California Health Care System in Fresno.

This evaluation focused on five key content domains:
•    Culture
•    Environment of care
•    Patient safety
•    Primary care
•    Veteran-centered safety net

The OIG issued seven recommendations for VA to correct identified deficiencies in three domains:
1.    Environment of care
•    Badge holder responsibilities
•    Signs
•    Privacy curtains, preventive equipment maintenance, splash resistant bottom shelves
•    Expired, damaged, and contaminated medications
•    Pharmaceutical grade medication refrigerators
2.    Primary care
•    Staffing
3.    Veteran-centered safety net
•    Housing and Urban Development–Veterans Affairs Supportive Housing program staffing

Report Type

Inspection / Evaluation

Location

CA
United States

Number of Recommendations

Questioned Costs

Funds for Better Use

Report updated under NDAA 5274

External Link

https://www.vaoig.gov/reports/healthcare-facility-inspection/healthcare-facilit…

Open Recommendations

This report has 5 open recommendations.

Recommendation Number	Significant Recommendation	Recommended Questioned Costs	Recommended Funds for Better Use
01	No	$0	$0
The Executive Director ensures staff receive education about badge holders’ responsibilities in preventing unauthorized access to VA facilities and computer systems and safeguarding electronic databases including electronic health care records.
04	No	$0	$0
The Executive Director ensures staff monitor patient care areas for expired, damaged, and contaminated medications and remove them as needed.
05	No	$0	$0
The Executive Director ensures staff store medications in pharmaceutical grade refrigerators.
06	No	$0	$0
The Executive Director ensures primary care staffing is sufficient for patients to receive appropriate health care.
07	No	$0	$0
The Executive Director reviews staffing levels for the Housing and Urban Development–Veterans Affairs Supportive Housing program and takes action as needed.