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California CDPH state citations and administrative penalties, 1997 to early 2024 (archived dataset). Separate from federal CMS deficiencies.
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G2 | H· | I· |
| Potential harm | D53 | E18 | F6 |
| Minimal | A· | B· |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Jul 2, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| May 21, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Apr 15, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Feb 13, 2026 | Fire safety | Fire Safety Standard | 4 | Potential harm | — | Open → |
| Feb 13, 2026 | Health | Health Standard | 15 | Potential harm | — | Open → |
| Sep 10, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Sep 9, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| May 9, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jan 8, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Oct 18, 2024 | Fire safety | Fire Safety Standard | 13 | Potential harm | — | Open → |
| Oct 18, 2024 | Health | Health Standard | 7 | Potential harm | — | Open → |
| Jul 16, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jun 6, 2024 | Health | Health Complaint | 5 | Actual harm | — | Open → |
| Mar 21, 2024 | Health | Health Complaint | 3 | Actual harm | — | Open → |
| Feb 8, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jan 17, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Dec 29, 2023 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Dec 21, 2023 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Oct 30, 2023 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Nov 4, 2021 | Fire safety | Fire Safety Standard | 11 | Potential harm | — | Open → |
| Nov 4, 2021 | Health | Health Standard | 10 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Jun 6, 2024 | Civil money penalty (fine) | $8,990 | — | 555153|Fine|130586 |
| Issued | Class | Type | Category | Final amount | Flags | Record |
|---|---|---|---|---|---|---|
| May 2, 2024 violation Nov 4, 2023 | Class A | Citation Citation A (HSC 1424) | Patient Care | $17,200 | Closed | 030020068 |
| Feb 20, 2024 violation Oct 1, 2020 | AP NHPPD | Administrative Penalty AP - 3.2 Nursing-Hours-per-Patient-Day AP (HSC 1276.5) | DHPPD: 2 - 11 Days | $25,000 | Closed | 810019728 |
| Feb 27, 2021 violation Apr 8, 2019 | FTR RES | Failure to Report Penalty Failure to Report Breach to Resident (HSC 1280.15(b)(2)) | Deliberate breach of PHI by health care worker | $3,100 | Open | 030019048 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G2 | H· | I· |
| Potential harm | D53 | E18 | F6 |
| Minimal | A· | B· | C4 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Jul 2, 2026 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 13, 2026 | Complaint |
| May 21, 2026 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 2, 2026 | Complaint |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
13 facilities in 1 states. CMS chain ID 175.
Chain average overall rating (CMS): 4
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Cypress Healthcare Group LLC | Organization | Direct owner | DIRECT OWNERSHIP INTEREST | not provided | Sep 29, 2023 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Cypress Healthcare Group LLC | Organization | Direct owner | DIRECT OWNERSHIP INTEREST | not provided | Sep 29, 2023 |
| Brandon Bernt | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Feb 6, 2024 |
| Amber Christian | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 3, 2024 |
| Lawanda Dale | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Nov 29, 2023 |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Sherwood Healthcare Center 4700 Elvas Ave, Sacramento, CA 95819 CCN 055305 | 62 | May 9, 2025 | 47 | — | |
| Saylor Lane Healthcare Center 3500 Folsom Boulevard, Sacramento, CA 95816 CCN 055417 | 42 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Citrus Heights Post Acute 7807 Uplands Way, Citrus Heights, CA 95610 CCN 5553374 state class AA/A | 2.1 km | 162 | Apr 23, 2026 | 42 | — | |
| Manzanita Healthcare Center 5318 Manzanita Avenue, Carmichael, CA 95608 CCN 5550833 state class AA/A | 6.1 km | 99 | Apr 15, 2026 | 671 harm | — | |
| Sacramento Post-Acute 5255 Hemlock Street, Sacramento, CA 95841 CCN 0560736 state class AA/A | 7 km | 99 | Feb 20, 2026 | 53 | — | |
| American River Center 3900 Garfield Avenue, Carmichael, CA 95608 CCN 5554502 state class AA/A | 7.3 km | 99 | Apr 10, 2026 | 36 | — | |
| Casa Coloma Health Care Center 10410 Coloma Rd, Rancho Cordova, CA 95670 CCN 0564951 state class AA/A | 7.4 km | 138 | Apr 24, 2026 | 78 | — | |
| College Oak Nursing and Rehabilitation Center 4635 College Oak Drive, Sacramento, CA 95841 CCN 0561584 state class AA/A | 7.9 km | 120 | Aug 12, 2026 | 401 IJ1 harm1 open | $9,814 | |
| Mountain Manor Senior Residence 6101 Fair Oaks Boulevard, Carmichael, CA 95608 CCN 5558891 state class AA/A | 7.9 km | 47 | Mar 10, 2026 | 71 | $39k | |
| River Pointe Post-Acute 6041 Fair Oaks Boulevard, Carmichael, CA 95608 CCN 0561013 state class AA/AAbuse icon | 8 km | 112 | Aug 13, 2026 | 862 harm | $9,870 |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 555153 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 555153 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
| California CDPH Licensed Facility Listing CA | 030000071 | state_license, licensed_beds, licensee Linked to the CMS record by exact CCN. | Verified | Oct 16, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Feb 27, 2021 violation Apr 8, 2019 | AP BR | Administrative Penalty AP - Breach (HSC 1280.15) | Deliberate breach of PHI by health care worker | $246,900 | Appealed Open | 030019046 |
| Jul 10, 2019 violation May 3, 2017 | Class B | Citation Citation B (HSC 1424) | Abuse/Facility Not Self Reported | $2,000 | Closed | 030015190 |
| May 14, 2019 violation Nov 29, 2018 | Class A | Citation Citation A (HSC 1424) | Patient Care | $20,000 | Appealed Open | 030015037 |
| Aug 24, 2010 violation Aug 11, 2008 | Class B | Citation Citation B (HSC 1424) | Patient Rights | $800 | Appealed Closed | 030007509 |
| Jan 13, 2010 violation Sep 13, 2006 | Class B | Citation Citation B (HSC 1424) | Patient Care | $1,000 | Closed | 030006909 |
| Dec 16, 2008 violation Apr 18, 2006 | Class A | Citation Citation A (HSC 1424) | Patient Care | $10,000 | Closed | 030005693 |
| Oct 11, 2007 violation Jul 11, 2005 | Class B | Citation Citation B (HSC 1424) | Patient Care | $1,000 | Closed | 030004342 |
| Jul 26, 2007 violation Aug 27, 2005 | Class A | Citation Citation A (HSC 1424) | Patient Care | $12,350 initial $15,000 | Appealed Closed | 030004128 |
| Jul 26, 2007 violation Aug 25, 2005 | Class B | Citation Citation B (HSC 1424) | Patient Care | $1,350 initial $1,000 | Appealed Closed | 030003780 |
| Oct 25, 2006 violation May 27, 2006 | Class B | Citation Citation B (HSC 1424) | Problem Transfer | $1,000 | Closed | 030003440 |
| Oct 2, 2006 violation Oct 13, 2005 | Class A | Citation Citation A (HSC 1424) | Patient Care | $15,000 | Closed | 030003370 |
| Jun 14, 2006 violation Jan 2, 2006 | Class B | Citation Citation B (HSC 1424) | Abuse/Facility Not Self Reported | $500 | Closed | 030003150 |
| Aug 1, 2005 violation Apr 9, 2004 | Class B | Citation Citation B (HSC 1424) | Patient Care | $1,000 | Closed | 030002330 |
| Mar 9, 2005 violation Sep 15, 2004 | Class B | Citation Citation B (HSC 1424) | Patient Care | $1,000 | Closed | 030002316 |
| Nov 4, 2002 violation Jul 27, 2002 | Class B | Citation Citation B (HSC 1424) | Patient Care | $500 initial $700 | Appealed Closed | 030002112 |
| Jul 22, 2002 violation Mar 20, 2002 | Class AA | Citation Citation AA (HSC 1424) | Patient Care | $55,000 initial $90,000 | Death relatedAppealed Closed | 030002098 |
| Aug 31, 2001 violation Mar 20, 2000 | Class A | Citation Citation A (HSC 1424) | Patient Care | $11,000 initial $15,000 | Appealed Closed | 030002075 |
| Apr 15, 2026 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 8, 2026 | Complaint |
| Feb 13, 2026 | K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Feb 23, 2026 |
| Feb 13, 2026 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 3, 2026 |
| Feb 13, 2026 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 3, 2026 |
| Feb 13, 2026 | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 3, 2026 |
| Feb 13, 2026 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Feb 13, 2026 | F-0584 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Feb 13, 2026 | F-0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Mar 13, 2026 |
| Feb 13, 2026 | F-0605 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Feb 13, 2026 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Feb 13, 2026 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Feb 13, 2026 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Feb 13, 2026 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Feb 13, 2026 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Feb 13, 2026 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Feb 13, 2026 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Mar 13, 2026 |
| Feb 13, 2026 | F-0808 | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Mar 13, 2026 |
| Feb 13, 2026 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Mar 13, 2026 |
| Feb 13, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Mar 13, 2026 |
| Feb 13, 2026 | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Sep 10, 2025 | F-0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 3, 2025 | Complaint |
| Sep 9, 2025 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 19, 2025 | Complaint |
| May 9, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 30, 2025 | Complaint |
| Jan 8, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 24, 2025 | Complaint |
| Jan 8, 2025 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 24, 2025 | Complaint |
| Oct 18, 2024 | E-0041 | Implement emergency and standby power systems. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Nov 6, 2024 |
| Oct 18, 2024 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 30, 2024 |
| Oct 18, 2024 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 31, 2024 |
| Oct 18, 2024 | K-0347 | Properly provide smoke detection systems in areas open to corridors. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 29, 2024 |
| Oct 18, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 31, 2024 |
| Oct 18, 2024 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 31, 2024 |
| Oct 18, 2024 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 4, 2024 |
| Oct 18, 2024 | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 4, 2024 |
| Oct 18, 2024 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 1, 2024 |
| Oct 18, 2024 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 8, 2024 |
| Oct 18, 2024 | F-0693 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 8, 2024 |
| Oct 18, 2024 | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 8, 2024 |
| Oct 18, 2024 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Nov 8, 2024 |
| Oct 18, 2024 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Nov 8, 2024 |
| Oct 18, 2024 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Nov 8, 2024 |
| Oct 18, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Nov 8, 2024 |
| Oct 18, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Oct 24, 2024 |
| Oct 18, 2024 | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Oct 31, 2024 |
| Oct 18, 2024 | K-0711 | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Oct 31, 2024 |
| Oct 18, 2024 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Nov 8, 2024 |
| Jul 16, 2024 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 31, 2024 | Complaint |
| Jun 6, 2024 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Jul 9, 2024 | Complaint |
| Jun 6, 2024 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 9, 2024 | Complaint |
| Jun 6, 2024 | F-0642 | Ensure a qualified health professional conducts resident assessments. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 9, 2024 | Complaint |
| Jun 6, 2024 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 9, 2024 | Complaint |
| Jun 6, 2024 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 9, 2024 | Complaint |
| Mar 21, 2024 | F-0687 | Provide appropriate foot care. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Apr 17, 2024 | Complaint |
| Mar 21, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Apr 17, 2024 | Complaint |
| Mar 21, 2024 | F-0882 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Apr 17, 2024 | Complaint |
| Feb 8, 2024 | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Feb 15, 2024 | Complaint |
| Jan 17, 2024 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 20, 2024 | Complaint |
| Jan 17, 2024 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 20, 2024 | Complaint |
| Dec 29, 2023 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 20, 2024 | Complaint |
| Dec 21, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Jan 28, 2024 | Complaint |
| Oct 30, 2023 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 9, 2023 | Complaint |
| Nov 4, 2021 | E-0006 | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Dec 8, 2021 |
| Nov 4, 2021 | K-0161 | Use approved construction type or materials. Construction Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 8, 2021 |
| Nov 4, 2021 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 8, 2021 |
| Nov 4, 2021 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 8, 2021 |
| Nov 4, 2021 | K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 8, 2021 |
| Nov 4, 2021 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 8, 2021 |
| Nov 4, 2021 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Dec 8, 2021 |
| Nov 4, 2021 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Dec 8, 2021 |
| Nov 4, 2021 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 8, 2021 |
| Nov 4, 2021 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 8, 2021 |
| Nov 4, 2021 | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 8, 2021 |
| Nov 4, 2021 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 3, 2021 |
| Nov 4, 2021 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 3, 2021 |
| Nov 4, 2021 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 3, 2021 |
| Nov 4, 2021 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 3, 2021 |
| Nov 4, 2021 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Dec 3, 2021 |
| Nov 4, 2021 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Dec 3, 2021 |
| Nov 4, 2021 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Dec 3, 2021 |
| Nov 4, 2021 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Dec 3, 2021 |
| Nov 4, 2021 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Dec 3, 2021 |
| Nov 4, 2021 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Dec 3, 2021 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.63 (case-mix index 1.32).
| Sunil Dhir | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 1, 2023 |
| Kalesia Evans | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Oct 21, 2024 |
| Myrna Garland | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Aug 16, 2024 |
| Alec Jackson | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 29, 2023 |
| Matthew Jackson | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 29, 2023 |
| Robert Jackson | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 29, 2023 |
| Lisa Jurgens | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 29, 2023 |
| Josephine Mewborn | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 4, 2024 |
| Matthew Jackson | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Sep 29, 2023 |
| Robert Jackson | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Sep 29, 2023 |
| Brandon Bernt | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Feb 6, 2024 |
| Amber Christian | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Apr 3, 2024 |
| Lawanda Dale | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Nov 29, 2023 |
| Sunil Dhir | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Apr 1, 2023 |
| Kalesia Evans | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Oct 21, 2024 |
| Myrna Garland | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Aug 16, 2024 |
| Alec Jackson | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Sep 29, 2023 |
| Matthew Jackson | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Sep 29, 2023 |
| Robert Jackson | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Sep 29, 2023 |
| Lisa Jurgens | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Sep 29, 2023 |
| Josephine Mewborn | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 4, 2024 |
| May 8, 2025 |
80 |
| — |
| Oak Ridge Healthcare Center 310 Oak Ridge Drive, Roseville, CA 95661 CCN 0554911 state class AA/A | 67 | Jun 8, 2026 | 54 | — |
| Spring Hill Manor 355 Joerschke Dr, Grass Valley, CA 95945 CCN 055640 | 86 | Aug 14, 2026 | 521 harm1 open | — |
| College Oak Nursing and Rehabilitation Center 4635 College Oak Drive, Sacramento, CA 95841 CCN 0561584 state class AA/A | 120 | Aug 12, 2026 | 401 IJ1 harm1 open | $9,814 |
| Manzanita Healthcare Center 5318 Manzanita Avenue, Carmichael, CA 95608 CCN 5550833 state class AA/A | 99 | Apr 15, 2026 | 671 harm | — |
| Greenhaven Healthcare Center 455 Florin Road, Sacramento, CA 95831 CCN 5550981 state class AA/AAbuse icon | 148 | Jun 11, 2026 | 1031 harm | — |
| Gold Country Health Center 4301 Golden Center Drive, Placerville, CA 95667 CCN 5551801 state class AA/A | 68 | Jul 16, 2026 | 802 harm | — |