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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 | G7 | H1 | I· |
| Potential harm | D42 | E30 | F12 |
| 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 17, 2026 | Fire safety | Fire Safety Standard | 8 | Potential harm | — | Open → |
| Jul 17, 2026 | Health | Health Complaint, Health Standard | 5 | Actual harm | — | Open → |
| May 8, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| May 4, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Mar 4, 2026 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Aug 13, 2025 | Health | Health Complaint | 2 | Actual harm | — | Open → |
| Jul 8, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Apr 21, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Feb 6, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Sep 19, 2024 | Fire safety | Fire Safety Standard | 9 | Potential harm | — | Open → |
| Sep 19, 2024 | Health | Health Standard | 2 | Potential harm | — | Open → |
| Sep 3, 2024 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Jun 11, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Feb 28, 2024 | Health | Health Complaint | 2 | Actual harm | 1 | Open → |
| Feb 27, 2024 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Feb 15, 2024 | Health | Health Complaint | 6 | Actual harm | — | Open → |
| Feb 14, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jan 4, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Nov 22, 2023 | Health | Health Complaint | 5 | Potential harm | — | Open → |
| May 19, 2021 | Fire safety | Fire Safety Standard | 13 | Potential harm | — | Open → |
| May 19, 2021 | Health | Health Standard | 23 | Actual harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Jul 8, 2025 | Civil money penalty (fine) | $79,560 | — | 555214|Fine|134960 |
| Jan 4, 2024 | Civil money penalty (fine) | $61,204 | — | 555214|Fine|130515 |
| Oct 17, 2023 | Civil money penalty (fine) | $2,447 | — | 555214|Fine|129118 |
| Issued | Class | Type | Category | Final amount | Flags | Record |
|---|---|---|---|---|---|---|
| May 7, 2024 violation Nov 29, 2020 | AP NHPPD | Administrative Penalty AP - 3.2 Nursing-Hours-per-Patient-Day AP (HSC 1276.5) | DHPPD: 2 - 11 Days | $25,000 | Closed | 810020081 |
| Jan 5, 2022 violation Oct 1, 2019 | AP NHPPD | Administrative Penalty AP - 3.2 Nursing-Hours-per-Patient-Day AP (HSC 1276.5) | DHPPD: 12 - 24 Days | $30,000 | Closed | 810017233 |
| Jul 29, 2021 violation Jul 29, 2020 | Class A | Citation Citation A (HSC 1424) | Patient Care | $20,000 | Closed | 110016072 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G7 | H1 | I· |
| Potential harm | D42 | E30 | F12 |
| Minimal | A· | B· | C· |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Jul 17, 2026 | 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 Aug 10, 2026 | Complaint |
| Jul 17, 2026 | K-0341 | Install a fire alarm system that can be heard throughout the facility. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 30, 2026 | |
| Jul 17, 2026 |
“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.
32 facilities in 1 states. CMS chain ID 98.
Chain average overall rating (CMS): 2.6
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Crescent Facilities Operations LLC | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Dec 19, 2006 |
| Win Win Enterprises, LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 35% | Feb 1, 2007 |
| Jenmax Enterprises LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 23% | Feb 1, 2007 |
| Jk-Csh Jv LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 12% | Nov 1, 2006 |
| Manhattan Five Partners LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 7% | Nov 1, 2006 |
| Bering Properties LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 6% | Feb 1, 2007 |
| Bh Alliance | Organization | Indirect owner | INDIRECT OWNERSHIP INTEREST | not provided | Nov 1, 2006 |
| The Jacob Wintner Trust | Organization | Indirect owner | INDIRECT OWNERSHIP INTEREST | not provided | Nov 1, 2006 |
| The Wintner Living Trust Dated 7/08/1992 | Organization | Indirect owner | INDIRECT OWNERSHIP INTEREST | not provided | Feb 1, 2007 |
| Jacob Wintner | Individual | Indirect owner | INDIRECT OWNERSHIP INTEREST | not provided | Feb 1, 2007 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Crescent Facilities Operations LLC | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Dec 19, 2006 |
| Win Win Enterprises, LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 35% | Feb 1, 2007 |
| Jenmax Enterprises LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 23% | Feb 1, 2007 |
| Jk-Csh Jv LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 12% | Nov 1, 2006 |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Madera Rehabilitation & Nursing Center 517 South a Street, Madera, CA 93638 CCN 0551471 state class AA/A | 176 | Feb 24, 2026 | 1001 IJ6 harm | $374k | |
| Watsonville Nursing Center |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Pine Ridge Care Center 45 Professional Center Pkwy, San Rafael, CA 94903 CCN 05585020 state class AA/AAbuse icon | 0 km | 101 | Feb 12, 2026 | 67 | — | |
| Northgate Postacute Care 40 Professional Center Parkway, San Rafael, CA 94903 CCN 0564303 state class AA/AAbuse icon | 0 km | 52 | Aug 27, 2026 | 842 harm1 open | — | |
| Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway, San Rafael, CA 94903 CCN 555595 | 1.3 km | 80 | Jun 9, 2026 | 65 | — | |
| Villa Marin 100 Thorndale Drive, San Rafael, CA 94903 CCN 555227 | 1.3 km | 31 | Aug 6, 2026 | 471 harm | — | |
| Marin Post Acute 234 N. San Pedro Rd, San Rafael, CA 94903 CCN 055310Abuse icon | 2 km | 168 | Aug 25, 2026 | 963 harm5 open | $8,278 | |
| San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue, San Rafael, CA 94901 CCN 0553313 state class AA/A | 4.1 km | 54 | Aug 7, 2026 | 841 harm | $8,278 | |
| The Tamalpais 501 Via Casitas, Greenbrae, CA 94904 CCN 056077 | 7.3 km | 52 | Sep 11, 2025 | 29 | — | |
| South Marin Health & Wellness Center 1220 South Eliseo Drive, Greenbrae, CA 94904 CCN 055093 | 7.5 km | 72 | Jan 23, 2026 | 57 | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 555214 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 555214 | 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 | 010000968 | 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
| Mar 13, 2020 violation Aug 6, 2015 |
| Class AA |
| Citation Citation AA (HSC 1424) |
| Patient Care |
| $100,000 |
Closed |
| 110012745 |
| Oct 10, 2019 violation Apr 24, 2019 | Class B | Citation Citation B (HSC 1424) | Patient Care | $2,000 | Closed | 110015325 |
| May 29, 2019 violation Aug 3, 2018 | Class A | Citation Citation A (HSC 1424) | Patient Care | $20,000 | Closed | 110014932 |
| May 29, 2019 violation Aug 11, 2018 | Class A | Citation Citation A (HSC 1424) | Patient Care | $20,000 | Closed | 110014895 |
| Jan 31, 2017 violation Jul 19, 2015 | Class A | Citation Citation A (HSC 1424) | Patient Care | $20,000 | Death related Closed | 110012609 |
| Sep 16, 2016 violation Jul 7, 2015 | Class B | Citation Citation B (HSC 1424) | Patient Care | $2,000 | Closed | 110012316 |
| Mar 8, 2016 violation Jun 23, 2014 | Class A | Citation Citation A (HSC 1424) | Patient Care | $15,000 initial $20,000 | Appealed Closed | 110011956 |
| Mar 8, 2016 violation Jul 8, 2014 | Class A | Citation Citation A (HSC 1424) | Patient Care | $15,000 initial $20,000 | Appealed Closed | 110011954 |
| Apr 15, 2010 violation Jul 21, 2009 | Class B | Citation Citation B (HSC 1424) | Patient Care | $800 | Closed | 110006594 |
| Nov 26, 2008 violation Sep 14, 2008 | Class A | Citation Citation A (HSC 1424) | Other · Patient Care/Medication | $18,000 | Closed | 110005621 |
| Jun 5, 2008 violation Dec 27, 2007 | Class B | Citation Citation B (HSC 1424) | Other · Patient Care, Medication | $1,000 | Closed | 110004674 |
| Jun 3, 2008 violation Jun 25, 2007 | Class A | Citation Citation A (HSC 1424) | Patient Care | $18,000 | Closed | 110004509 |
| Feb 14, 2008 violation May 23, 2007 | Class A | Citation Citation A (HSC 1424) | Patient Care | $18,000 | Closed | 110004372 |
| Aug 14, 2007 violation Sep 7, 2006 | Class A | Citation Citation A (HSC 1424) | Patient Care | $8,000 initial $18,000 | Appealed Closed | 110004139 |
| Aug 14, 2007 violation Sep 7, 2006 | Class A | Citation Citation A (HSC 1424) | Patient Care | $8,000 initial $18,000 | Appealed Closed | 110004132 |
| Apr 26, 2007 violation Nov 11, 2006 | Class A | Citation Citation A (HSC 1424) | Other · A, C, P | $8,000 initial $18,000 | Appealed Closed | 110003545 |
| Nov 28, 2006 violation Jul 19, 2006 | Class A | Citation Citation A (HSC 1424) | Other · C, PE | $7,500 initial $16,000 | Appealed Closed | 110003248 |
| Jul 7, 2005 violation Feb 28, 2005 | Class B | Citation Citation B (HSC 1424) | Patient Care | $450 initial $750 | Appealed Closed | 010002161 |
| Jun 4, 2004 violation Jan 24, 2004 | Class B | Citation Citation B (HSC 1424) | Patient Rights | $360 initial $600 | Appealed Closed | 010002105 |
| Mar 4, 2004 violation Jan 22, 2004 | Class B | Citation Citation B (HSC 1424) | Patient Rights | $500 initial $1,000 | Appealed Closed | 010002090 |
| Nov 14, 2003 violation Dec 17, 2001 | Class B | Citation Citation B (HSC 1424) | Patient Rights | $480 initial $800 | Appealed Closed | 010002067 |
| Aug 22, 2003 violation Jul 20, 2003 | Class B | Citation Citation B (HSC 1424) | Patient Care | $250 initial $500 | Appealed Closed | 010002049 |
| Apr 3, 2003 violation Feb 1, 2003 | Class B | Citation Citation B (HSC 1424) | Other · C,PR | $600 initial $1,000 | Appealed Closed | 010002023 |
| Apr 3, 2003 violation Feb 1, 2003 | Class B | Citation Citation B (HSC 1424) | Other · C,PR | $600 initial $1,000 | Appealed Closed | 010002022 |
| Dec 3, 2002 violation May 31, 2002 | Class B | Citation Citation B (HSC 1424) | Other · PR C | $600 initial $1,000 | Appealed Closed | 010002001 |
| Oct 4, 2002 violation Feb 21, 2001 | Class B | Citation Citation A (HSC 1424) | Patient Care | $14,000 initial $16,000 | Appealed Closed | 010001993 |
| Apr 4, 2002 violation Oct 23, 2001 | Class B | Citation Citation B (HSC 1424) | Patient Rights | $500 initial $750 | Appealed Closed | 010001937 |
| Apr 4, 2002 violation Nov 27, 2001 | Class B | Citation Citation B (HSC 1424) | Patient Rights | $750 | Appealed Closed | 010001936 |
| Nov 13, 2001 violation Sep 7, 1998 | Class B | Citation Citation B (HSC 1424) | Medication | $400 initial $800 | Appealed Closed | 010001905 |
| Oct 16, 2001 violation Jul 5, 2001 | Class B | Citation Citation B (HSC 1424) | Patient Care | $1,000 | Closed | 010001893 |
| Mar 13, 2000 violation Feb 17, 1999 | Class B | Citation Citation B (HSC 1424) | Patient Care | $2,000 initial $1,000 | Appealed Closed | 010001724 |
| K-0345 |
| Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety |
| F · Potential harm Widespread |
| Corrected Jul 23, 2026 |
| Jul 17, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 3, 2026 |
| Jul 17, 2026 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 3, 2026 |
| Jul 17, 2026 | K-0711 | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 3, 2026 |
| Jul 17, 2026 | 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 Aug 10, 2026 |
| Jul 17, 2026 | K-0919 | Meet requirements for the use of electrical equipment. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 3, 2026 |
| Jul 17, 2026 | 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 Aug 3, 2026 |
| Jul 17, 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 Aug 10, 2026 | Complaint |
| Jul 17, 2026 | F-0688 | 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. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Aug 10, 2026 |
| Jul 17, 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 Aug 10, 2026 |
| Jul 17, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Aug 10, 2026 |
| May 8, 2026 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 4, 2026 | Complaint |
| May 4, 2026 | 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 May 29, 2026 | Complaint |
| Mar 4, 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 5, 2026 | Complaint |
| Mar 4, 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 | D · Potential harm Isolated | Corrected Mar 5, 2026 | Complaint |
| Aug 13, 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 | G · Actual harm Isolated | Corrected Sep 18, 2025 | Complaint |
| Aug 13, 2025 | F-0557 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 18, 2025 | Complaint |
| Jul 8, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Aug 8, 2025 | Complaint |
| Apr 21, 2025 | 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 May 12, 2025 | Complaint |
| Feb 6, 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 Feb 11, 2025 | Complaint |
| Sep 19, 2024 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 7, 2024 |
| Sep 19, 2024 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 7, 2024 |
| Sep 19, 2024 | K-0347 | Properly provide smoke detection systems in areas open to corridors. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 7, 2024 |
| Sep 19, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 7, 2024 |
| Sep 19, 2024 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 7, 2024 |
| Sep 19, 2024 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 7, 2024 |
| Sep 19, 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 7, 2024 |
| Sep 19, 2024 | 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 Nov 7, 2024 |
| Sep 19, 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 7, 2024 |
| Sep 19, 2024 | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Oct 8, 2024 |
| Sep 19, 2024 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Oct 8, 2024 |
| Sep 3, 2024 | 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 20, 2024 | Complaint |
| Sep 3, 2024 | 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 Sep 20, 2024 | Complaint |
| Sep 3, 2024 | 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 Sep 20, 2024 | Complaint |
| Jun 11, 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 | E · Potential harm Pattern | Corrected Jun 18, 2024 | Complaint |
| Feb 28, 2024 | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Plan of correction, not yet verified Mar 28, 2024 | Complaint |
| Feb 28, 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 Mar 28, 2024 | Complaint |
| Feb 27, 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 Mar 15, 2024 | Complaint |
| Feb 27, 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 | E · Potential harm Pattern | Corrected Mar 15, 2024 | Complaint |
| Feb 27, 2024 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Mar 15, 2024 | Complaint |
| Feb 15, 2024 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Mar 28, 2024 | Complaint |
| Feb 15, 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 Mar 28, 2024 | Complaint |
| Feb 15, 2024 | F-0553 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Mar 28, 2024 | Complaint |
| Feb 15, 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 | E · Potential harm Pattern | Corrected Mar 28, 2024 | Complaint |
| Feb 15, 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 Mar 28, 2024 | Complaint |
| Feb 15, 2024 | 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 Mar 28, 2024 | Complaint |
| Feb 14, 2024 | F-0557 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Mar 22, 2024 | Complaint |
| Jan 4, 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 Feb 27, 2024 | Complaint |
| Jan 4, 2024 | F-0776 | Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Feb 27, 2024 | Complaint |
| Nov 22, 2023 | 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 | E · Potential harm Pattern | Corrected Dec 24, 2023 | Complaint |
| Nov 22, 2023 | 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 | E · Potential harm Pattern | Corrected Dec 24, 2023 | Complaint |
| Nov 22, 2023 | 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 24, 2023 | Complaint |
| Nov 22, 2023 | 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 24, 2023 | Complaint |
| Nov 22, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Dec 24, 2023 | Complaint |
| May 19, 2021 | 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 | H · Actual harm Pattern | Corrected Aug 23, 2021 |
| May 19, 2021 | 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 | G · Actual harm Isolated | Corrected Aug 23, 2021 |
| May 19, 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 | G · Actual harm Isolated | Corrected Aug 23, 2021 |
| May 19, 2021 | E-0006 | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 8, 2021 |
| May 19, 2021 | E-0024 | Establish policies and procedures for volunteers. Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 8, 2021 |
| May 19, 2021 | E-0026 | Establish roles under a Waiver declared by secretary. Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 8, 2021 |
| May 19, 2021 | E-0030 | List the names and contact information of those in the facility. Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 8, 2021 |
| May 19, 2021 | E-0035 | Provide family notifications of emergency plan. Emergency Preparedness Deficiencies · Emergency preparedness | D · Potential harm Isolated | Corrected Jun 8, 2021 |
| May 19, 2021 | K-0161 | Use approved construction type or materials. Construction Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 8, 2021 |
| May 19, 2021 | K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 8, 2021 |
| May 19, 2021 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 8, 2021 |
| May 19, 2021 | K-0341 | Install a fire alarm system that can be heard throughout the facility. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 8, 2021 |
| May 19, 2021 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 8, 2021 |
| May 19, 2021 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 8, 2021 |
| May 19, 2021 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 8, 2021 |
| May 19, 2021 | K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 8, 2021 |
| May 19, 2021 | 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 | E · Potential harm Pattern | Corrected Aug 17, 2021 |
| May 19, 2021 | F-0572 | Give residents a notice of rights, rules, services and charges. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Aug 17, 2021 |
| May 19, 2021 | 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 | E · Potential harm Pattern | Corrected Aug 17, 2021 |
| May 19, 2021 | F-0656 | Develop 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 Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Aug 17, 2021 |
| May 19, 2021 | 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 | E · Potential harm Pattern | Corrected Aug 17, 2021 |
| May 19, 2021 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Aug 17, 2021 |
| May 19, 2021 | 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 Aug 17, 2021 |
| May 19, 2021 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 17, 2021 |
| May 19, 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 | E · Potential harm Pattern | Corrected Aug 17, 2021 |
| May 19, 2021 | 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 Aug 17, 2021 |
| May 19, 2021 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Aug 17, 2021 |
| May 19, 2021 | F-0726 | 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. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Aug 17, 2021 |
| May 19, 2021 | F-0727 | Have 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 Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Aug 17, 2021 |
| May 19, 2021 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Aug 17, 2021 |
| May 19, 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 | D · Potential harm Isolated | Corrected Aug 17, 2021 |
| May 19, 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 Aug 17, 2021 |
| May 19, 2021 | 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 | E · Potential harm Pattern | Corrected Aug 17, 2021 |
| May 19, 2021 | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Aug 17, 2021 |
| May 19, 2021 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Aug 17, 2021 |
| May 19, 2021 | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 17, 2021 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.08 (case-mix index 1.33).
| Manhattan Five Partners LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 7% | Nov 1, 2006 |
| Bering Properties LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 6% | Feb 1, 2007 |
| Bh Alliance | Organization | Indirect owner | INDIRECT OWNERSHIP INTEREST | not provided | Nov 1, 2006 |
| The Jacob Wintner Trust | Organization | Indirect owner | INDIRECT OWNERSHIP INTEREST | not provided | Nov 1, 2006 |
| The Wintner Living Trust Dated 7/08/1992 | Organization | Indirect owner | INDIRECT OWNERSHIP INTEREST | not provided | Feb 1, 2007 |
| Jacob Wintner | Individual | Indirect owner | INDIRECT OWNERSHIP INTEREST | not provided | Feb 1, 2007 |
| Gregory Bretsch | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Feb 25, 2019 |
| Nicole Foreman | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jan 8, 2024 |
| Cambridge Healthcare Services LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 1, 2014 |
| Gregory Bretsch | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Feb 25, 2019 |
| Julie Butenko | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 24, 2023 |
| Heidi Capela | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 3, 2023 |
| Noreen Copp | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 14, 2025 |
| Nicole Foreman | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 8, 2024 |
| Lance Hassell | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 25, 2022 |
| Linda Lutz | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Feb 1, 2012 |
| Paulina Salazar | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Dec 14, 2020 |
| Ira Smedra | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Feb 1, 2007 |
| Jacob Wintner | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Feb 1, 2007 |
| 81 Professional Center LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Dec 15, 2006 |
| Cambridge Healthcare Services LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Nov 5, 2025 |
| Jenmax Enterprises LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Dec 15, 2006 |
| Jk-Csh Jv LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Dec 15, 2006 |
| Win Win Enterprises, LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Dec 15, 2006 |
| Gregory Bretsch | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Feb 25, 2019 |
| Julie Butenko | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jul 24, 2023 |
| Heidi Capela | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Apr 3, 2023 |
| Nicole Foreman | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Nov 5, 2025 |
| Lance Hassell | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Apr 25, 2022 |
| Linda Lutz | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Feb 1, 2012 |
| Paulina Salazar | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Dec 14, 2020 |
| Ira Smedra | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Feb 1, 2007 |
| Jacob Wintner | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Feb 1, 2007 |
| 87 |
| Jan 9, 2026 |
56 |
| — |
| Merced Nursing & Rehabilitation Ctr 510 West 26th Street, Merced, CA 95340 CCN 055249 | 79 | Jul 17, 2026 | 46 | — |
| La Sierra Care Center 2424 M Street, Merced, CA 95340 CCN 055271 | 68 | Jan 23, 2026 | 61 | — |
| Valley Palms Care Center 13400 Sherman Way, N Hollywood, CA 91605 CCN 0552871 state class AA/A | 99 | May 18, 2026 | 1371 IJ1 harm | $34k |
| Monrovia Gardens Healthcare Center 615 W. Duarte Rd., Monrovia, CA 91016 CCN 0553673 state class AA/A | 96 | Jul 15, 2026 | 1191 harm | — |
| Huntington Drive Health and Rehabilitation Center 400 W. Huntinton Dr., Arcadia, CA 91007 CCN 0553763 state class AA/A | 99 | Jul 24, 2026 | 99 | — |
| Buena Vista Care Center 1440 S Euclid Avenue, Anaheim, CA 92802 CCN 055459 | 99 | May 11, 2026 | 1011 open | — |