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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 | D88 | E30 | F2 |
| 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 9, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jun 10, 2026 | Fire safety | Fire Safety Complaint | 1 | Potential harm | — | Open → |
| May 20, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| May 6, 2026 | Fire safety | Fire Safety Complaint | 1 | Potential harm | — | Open → |
| Apr 2, 2026 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Mar 12, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Dec 9, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Sep 2, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Aug 7, 2025 | Fire safety | Fire Safety Standard | 7 | Potential harm | — | Open → |
| Aug 7, 2025 | Health | Health Complaint, Health Standard | 23 | Potential harm | — | Open → |
| Jul 1, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jun 11, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Feb 19, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jan 29, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Oct 2, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jul 23, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jul 18, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jun 20, 2024 | Fire safety | Fire Safety Standard | 12 | Potential harm | — | Open → |
| Jun 20, 2024 | Health | Health Standard | 15 | Potential harm | — | Open → |
| May 17, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Apr 11, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Mar 27, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Mar 5, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Feb 26, 2024 | Health | Health Complaint | 1 | Actual harm | — | Open → |
| Jan 9, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Dec 6, 2023 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Oct 20, 2023 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Oct 17, 2023 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Oct 11, 2023 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jun 22, 2023 | Fire safety | Fire Safety Standard | 12 | Potential harm | — | Open → |
| Jun 22, 2023 | Health | Health Standard | 25 | Actual harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Feb 26, 2024 | Denial of payment for new admissions | — | Mar 29, 2024 · 21 days | 555736|Payment Denial|2024-03-29 |
| Feb 26, 2024 | Civil money penalty (fine) | $56,843 | — | 555736|Fine|130143 |
| Issued | Class | Type | Category | Final amount | Flags | Record |
|---|---|---|---|---|---|---|
| Mar 21, 2024 violation Feb 13, 2024 | Class B | Citation Citation B (HSC 1424) | Patient Care | $3,000 | Closed | 990019883 |
| Jan 29, 2024 violation Jun 21, 2023 | Class B | Citation Citation B (HSC 1424) | Patient Care | $3,600 initial $3,000 | Open | 990019732 |
| Mar 10, 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 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G2 | H· | I· |
| Potential harm | D88 | E30 | F2 |
| Minimal | A· | B· | C1 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Jul 9, 2026 | 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 Jul 10, 2026 | Complaint |
| Jun 10, 2026 | K-0531 | Have elevators that firefighters can control in the event of a fire. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 12, 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.
6 facilities in 1 states. CMS chain ID 692.
Chain average overall rating (CMS): 2.3
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Sonora Operations Holdings LLC | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Mar 1, 2023 |
| Ch Cafive Holdings LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 25% | Mar 1, 2023 |
| Cw Cafive Holdings LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 25% | Mar 1, 2023 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Sonora Operations Holdings LLC | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Mar 1, 2023 |
| Ch Cafive Holdings LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 25% | Mar 1, 2023 |
| Cw Cafive Holdings LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 25% | Mar 1, 2023 |
| Karen Barias | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Mar 1, 2023 |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Golden Heights Healthcare 35 Escuela Drive, Daly City, CA 94015 CCN 055968 | 102 | Jul 29, 2026 | 75 | — | |
| Golden Merced Care Center 3170 M Street, Merced, CA 95340 CCN 0559882 state class AA/A | 121 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Adventist Health Sonora - D/P SNF 179 South Fairview Lane, Sonora, CA 95370 CCN 5552091 state class AA/A | 1.8 km | 68 | Jan 23, 2026 | 49 | — | |
| Adventist Health Sonora - D/P SNF (Unit 7) 538 Ponderosa Drive, Sonora, CA 95370 CCN 050335State license only | 2.1 km | 36 lic. | Not CMS rated | — | No inspections in window | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 555736 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 555736 | 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 | 030001615 | 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
| 030017461 |
| Dec 13, 2021 violation Sep 29, 2018 | Class B | Citation Citation B (HSC 1424) | Patient Care | $2,000 | Death related Closed | 030017141 |
| Nov 9, 2021 violation Apr 3, 2021 | Class AA | Citation Citation AA (HSC 1424) | Patient Care | $75,000 | Death related Closed | 030017066 |
| Jul 30, 2020 violation Nov 28, 2018 | AP NHPPD | Administrative Penalty AP - 3.2 Nursing-Hours-per-Patient-Day AP (HSC 1276.5) | DHPPD: 1 Day (No Penalty) | $0 | Open | 810016005 |
| Oct 19, 2018 violation Mar 18, 2018 | Class B | Citation Citation B (HSC 1424) | Patient Care | $2,000 | Closed | 030014487 |
| Apr 20, 2018 violation Jan 17, 2017 | Class A | Citation Citation A (HSC 1424) | Patient Care | $20,000 | Death related Closed | 030014010 |
| Apr 20, 2016 violation Aug 23, 2014 | Class AA | Citation Citation AA (HSC 1424) | Patient Care | $50,000 initial $80,000 | Death relatedAppealed Closed | 030012183 |
| Apr 1, 2014 violation Apr 2, 2013 | AP NHPPD | Administrative Penalty AP - 3.2 Nursing-Hours-per-Patient-Day AP (HSC 1276.5) | DHPPD: 2 - 11 Days | $15,000 | Closed | 030010317 |
| Mar 3, 2011 violation Jun 1, 2008 | Class A | Citation Citation A (HSC 1424) | Patient Care | $11,700 initial $20,000 | Appealed Closed | 030007984 |
| Mar 3, 2011 violation Jun 15, 2008 | Class B | Citation Citation B (HSC 1424) | Patient Rights | $520 initial $800 | Appealed Closed | 030007983 |
| Jan 28, 2005 violation May 12, 2004 | Class B | Citation Citation B (HSC 1424) | Patient Care | $500 initial $1,000 | Appealed Closed | 030002314 |
| Jun 13, 2001 violation Jan 24, 2001 | Class A | Citation Citation A (HSC 1424) | Patient Care | $15,000 initial $20,000 | Appealed Closed | 030002068 |
| Jun 13, 2001 violation Jan 24, 2001 | Class A | Citation Citation AA (HSC 1424) | Patient Care | $55,000 initial $60,000 | Death relatedAppealed Closed | 030002067 |
| Jan 10, 2001 violation Mar 21, 2000 | Class A | Citation Citation A (HSC 1424) | Other · C,PR | $10,000 | Appealed Closed | 030002051 |
| May 20, 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 May 21, 2026 | Complaint |
| May 6, 2026 | K-0531 | Have elevators that firefighters can control in the event of a fire. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 7, 2026 | ComplaintIDR |
| Apr 2, 2026 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Apr 3, 2026 | Complaint |
| Apr 2, 2026 | F-0770 | Provide timely, quality laboratory services/tests to meet the needs of residents. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Apr 3, 2026 | Complaint |
| Mar 12, 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 | E · Potential harm Pattern | Corrected Mar 13, 2026 | Complaint |
| Dec 9, 2025 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Dec 10, 2025 | Complaint |
| Sep 2, 2025 | 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 Sep 3, 2025 | Complaint |
| Aug 7, 2025 | K-0161 | Use approved construction type or materials. Construction Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 12, 2025 |
| Aug 7, 2025 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 12, 2025 |
| Aug 7, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 12, 2025 |
| Aug 7, 2025 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 12, 2025 |
| Aug 7, 2025 | 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 12, 2025 |
| Aug 7, 2025 | 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 12, 2025 |
| Aug 7, 2025 | 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 Aug 8, 2025 |
| Aug 7, 2025 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 8, 2025 |
| Aug 7, 2025 | 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 Aug 8, 2025 | Complaint |
| Aug 7, 2025 | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Aug 8, 2025 |
| Aug 7, 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 Aug 8, 2025 |
| Aug 7, 2025 | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Aug 8, 2025 |
| Aug 7, 2025 | 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 | D · Potential harm Isolated | Corrected Aug 8, 2025 |
| Aug 7, 2025 | 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 Aug 8, 2025 |
| Aug 7, 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 Aug 8, 2025 |
| Aug 7, 2025 | 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 | D · Potential harm Isolated | Corrected Aug 8, 2025 |
| Aug 7, 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 Aug 8, 2025 |
| Aug 7, 2025 | 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 8, 2025 |
| Aug 7, 2025 | 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 Aug 8, 2025 |
| Aug 7, 2025 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Aug 8, 2025 |
| Aug 7, 2025 | 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 Aug 8, 2025 |
| Aug 7, 2025 | 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 Aug 8, 2025 |
| Aug 7, 2025 | F-0806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Aug 8, 2025 |
| Aug 7, 2025 | 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 8, 2025 |
| Aug 7, 2025 | F-0814 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Aug 8, 2025 |
| Aug 7, 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 Aug 8, 2025 | Complaint |
| Aug 7, 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 |
| Aug 7, 2025 | F-0881 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Aug 8, 2025 |
| Aug 7, 2025 | 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 8, 2025 |
| Aug 7, 2025 | K-0341 | Install a fire alarm system that can be heard throughout the facility. Smoke Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Aug 12, 2025 |
| Jul 1, 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 Jul 1, 2025 | Complaint |
| Jun 11, 2025 | F-0687 | Provide appropriate foot care. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 11, 2025 | Complaint |
| Feb 19, 2025 | 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 19, 2025 | Complaint |
| Feb 19, 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 Feb 19, 2025 | Complaint |
| Jan 29, 2025 | 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 Jan 29, 2025 | Complaint |
| Oct 2, 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 Oct 8, 2024 | Complaint |
| Jul 23, 2024 | F-0626 | Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 29, 2024 | Complaint |
| Jul 18, 2024 | 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 | D · Potential harm Isolated | Corrected Jul 29, 2024 | Complaint |
| Jul 18, 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 Jul 29, 2024 | Complaint |
| Jun 20, 2024 | K-0161 | Use approved construction type or materials. Construction Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 27, 2024 |
| Jun 20, 2024 | 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 Jun 27, 2024 |
| Jun 20, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 27, 2024 |
| Jun 20, 2024 | K-0347 | Properly provide smoke detection systems in areas open to corridors. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 27, 2024 |
| Jun 20, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 27, 2024 |
| Jun 20, 2024 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 27, 2024 |
| Jun 20, 2024 | K-0711 | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 27, 2024 |
| Jun 20, 2024 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 27, 2024 |
| Jun 20, 2024 | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 27, 2024 |
| Jun 20, 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 | E · Potential harm Pattern | Corrected Jun 27, 2024 |
| Jun 20, 2024 | K-0919 | Meet requirements for the use of electrical equipment. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 27, 2024 |
| Jun 20, 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 Jun 27, 2024 |
| Jun 20, 2024 | 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 Jun 20, 2024 |
| Jun 20, 2024 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 20, 2024 |
| Jun 20, 2024 | F-0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 20, 2024 |
| Jun 20, 2024 | F-0567 | Honor the resident's right to manage his or her financial affairs. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jun 20, 2024 |
| Jun 20, 2024 | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 20, 2024 |
| Jun 20, 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 | D · Potential harm Isolated | Corrected Jun 20, 2024 |
| Jun 20, 2024 | F-0694 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 20, 2024 |
| Jun 20, 2024 | 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 Jun 20, 2024 |
| Jun 20, 2024 | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 20, 2024 |
| Jun 20, 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 | D · Potential harm Isolated | Corrected Jun 20, 2024 |
| Jun 20, 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 | D · Potential harm Isolated | Corrected Jun 20, 2024 |
| Jun 20, 2024 | F-0803 | 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. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Jun 20, 2024 |
| Jun 20, 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 Jun 20, 2024 |
| Jun 20, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jun 20, 2024 |
| May 17, 2024 | F-0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 23, 2024 | Complaint |
| Apr 11, 2024 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Apr 19, 2024 | Complaint |
| Mar 27, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Apr 17, 2024 | Complaint |
| Mar 5, 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 Apr 5, 2024 | Complaint |
| Feb 26, 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 18, 2024 | Complaint |
| Jan 9, 2024 | 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 | D · Potential harm Isolated | Corrected Feb 9, 2024 | Complaint |
| Jan 9, 2024 | F-0758 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Feb 9, 2024 | Complaint |
| Dec 6, 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 Jan 3, 2024 | Complaint |
| Oct 20, 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 8, 2023 | Complaint |
| Oct 17, 2023 | 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 Oct 20, 2023 | Complaint |
| Oct 11, 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 | D · Potential harm Isolated | Corrected Oct 30, 2023 | Complaint |
| Jun 22, 2023 | 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 | G · Actual harm Isolated | Corrected Jul 19, 2023 |
| Jun 22, 2023 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 5, 2023 |
| Jun 22, 2023 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 5, 2023 |
| Jun 22, 2023 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 5, 2023 |
| Jun 22, 2023 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 5, 2023 |
| Jun 22, 2023 | 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 Jul 5, 2023 |
| Jun 22, 2023 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 5, 2023 |
| Jun 22, 2023 | K-0711 | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 5, 2023 |
| Jun 22, 2023 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 5, 2023 |
| Jun 22, 2023 | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 5, 2023 |
| Jun 22, 2023 | K-0919 | Meet requirements for the use of electrical equipment. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 5, 2023 |
| Jun 22, 2023 | 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 Jul 5, 2023 |
| Jun 22, 2023 | K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 5, 2023 |
| Jun 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 | D · Potential harm Isolated | Corrected Jul 19, 2023 |
| Jun 22, 2023 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 19, 2023 |
| Jun 22, 2023 | F-0568 | Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 19, 2023 |
| Jun 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 | D · Potential harm Isolated | Corrected Jul 19, 2023 |
| Jun 22, 2023 | 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 Jul 19, 2023 |
| Jun 22, 2023 | 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 Jul 19, 2023 |
| Jun 22, 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 Jul 19, 2023 |
| Jun 22, 2023 | 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 | E · Potential harm Pattern | Corrected Jul 19, 2023 |
| Jun 22, 2023 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 19, 2023 |
| Jun 22, 2023 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jul 19, 2023 |
| Jun 22, 2023 | 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 Jul 19, 2023 |
| Jun 22, 2023 | F-0687 | Provide appropriate foot care. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 19, 2023 |
| Jun 22, 2023 | 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 Jul 19, 2023 |
| Jun 22, 2023 | F-0694 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 19, 2023 |
| Jun 22, 2023 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jul 19, 2023 |
| Jun 22, 2023 | 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 Jul 19, 2023 |
| Jun 22, 2023 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jul 19, 2023 |
| Jun 22, 2023 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Jul 19, 2023 |
| Jun 22, 2023 | 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 Jul 19, 2023 |
| Jun 22, 2023 | 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 Jul 19, 2023 |
| Jun 22, 2023 | F-0806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Jul 19, 2023 |
| Jun 22, 2023 | 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 | F · Potential harm Widespread | Corrected Jul 19, 2023 |
| Jun 22, 2023 | 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 Jul 19, 2023 |
| Jun 22, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jul 19, 2023 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.78 (case-mix index 1.19).
| Steven Earl | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Mar 1, 2023 |
| Couve Healthcare Consulting LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Aug 31, 2023 |
| Sonora Opco Manager LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 1, 2023 |
| Sonora SNF Consulting LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 1, 2023 |
| Sonora SNF Operations LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 1, 2023 |
| Veritas Health Solutions LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 1, 2023 |
| Karen Barias | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 1, 2023 |
| Steven Earl | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 1, 2023 |
| Genesis Leininger | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 1, 2023 |
| Daniel Meador | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 1, 2023 |
| Shimon Spielman | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 1, 2023 |
| Yitzchok Yenowitz | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 1, 2023 |
| Shimon Spielman | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Mar 1, 2023 |
| Yitzchok Yenowitz | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Mar 1, 2023 |
| Ch Cafive Holdings LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2023 |
| Couve Healthcare Consulting LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Apr 15, 2025 |
| Cw Cafive Holdings LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2023 |
| Sonora Opco Manager LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Apr 15, 2025 |
| Sonora SNF Consulting LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Apr 15, 2025 |
| Sonora SNF Operations LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Apr 15, 2025 |
| Sonora SNF Realty LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Apr 15, 2025 |
| Veritas Health Solutions LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Apr 15, 2025 |
| Witzcorp LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2023 |
| Karen Barias | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2023 |
| Steven Earl | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2023 |
| Yisroel Herzka | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2023 |
| Genesis Leininger | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2023 |
| Daniel Meador | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2023 |
| Shimon Spielman | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2023 |
| Chava Wolofsky | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2023 |
| Yitzchok Yenowitz | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2023 |
| Aug 20, 2026 |
521 harm2 open |
| — |
| Golden San Andreas Care Center 900 Mountain Ranch Road, San Andreas, CA 95249 CCN 0561323 state class AA/A | 99 | Aug 26, 2026 | 1021 IJ5 harm | $67k |
| Golden Modesto Care Center 1900 Coffee Road, Modesto, CA 95355 CCN 0563011 state class AA/A | 120 | Jun 24, 2026 | 919 harm | $150k |
| Golden Pavilion Healthcare 99 Escuela Drive, Daly City, CA 94015 CCN 0563942 state class AA/ASFF Candidate | 239 | Jul 23, 2026 | 1183 harm | $56k |