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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 | G1 | H· | I· |
| Potential harm | D72 | E29 | F4 |
| Minimal | A· | B1 |
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 | |
|---|---|---|---|---|---|---|
| Aug 31, 2026 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Aug 25, 2026 | Health | Health Complaint | 2 | Potential harm | 2 | Open → |
| Aug 24, 2026 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Aug 18, 2026 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Aug 6, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jul 17, 2026 | Fire safety | Fire Safety Standard | 4 | Potential harm | — | Open → |
| Jul 17, 2026 | Health | Health Standard | 21 | Potential harm | — | Open → |
| Jul 10, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Dec 16, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| May 11, 2025 | Fire safety | Fire Safety Standard | 7 | Potential harm | — | Open → |
| May 11, 2025 | Health | Health Standard | 15 | Potential harm | — | Open → |
| Jan 23, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Sep 23, 2024 | Health | Health Complaint | 4 | Potential harm | — | Open → |
| Jun 5, 2024 | Fire safety | Fire Safety Standard | 3 | Potential harm | — | Open → |
| Jun 5, 2024 | Health | Health Complaint, Health Standard | 20 | Potential harm | — | Open → |
| May 1, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Feb 27, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Feb 5, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jan 16, 2024 | Health | Health Complaint | 4 | Actual harm | — | Open → |
| Dec 29, 2023 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Nov 30, 2023 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Nov 16, 2023 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Nov 7, 2023 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Issued | Class | Type | Category | Final amount | Flags | Record |
|---|---|---|---|---|---|---|
| Feb 29, 2024 violation Jan 13, 2024 | Class A | Citation Citation A (HSC 1424) | Patient Care | $75,000 initial $25,000 | Closed | 920019801 |
| Nov 14, 2023 violation Sep 14, 2023 | Class B | Citation Citation B (HSC 1424) | Patient Care | $3,000 | Appealed Open | 920019364 |
| Oct 16, 2023 violation Sep 20, 2023 | Class B | Citation Citation B (HSC 1424) |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D72 | E29 | F4 |
| Minimal | A· | B1 | C· |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Aug 31, 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 Sep 18, 2026 | Complaint |
| Aug 31, 2026 | 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 Sep 18, 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.
35 facilities in 2 states. CMS chain ID 50.
Chain average overall rating (CMS): 3.7
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Jacaranda Healthcare Group LLC | Organization | Direct owner | DIRECT OWNERSHIP INTEREST | not provided | Aug 9, 2022 |
| Jeffrey Bradshaw | Individual | Indirect owner | INDIRECT OWNERSHIP INTEREST | not provided | Aug 9, 2022 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Jacaranda Healthcare Group LLC | Organization | Direct owner | DIRECT OWNERSHIP INTEREST | not provided | Aug 9, 2022 |
| Jeffrey Bradshaw | Individual | Indirect owner | INDIRECT OWNERSHIP INTEREST | not provided | Aug 9, 2022 |
| Mark Gobrial | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Dec 1, 2023 |
| Stephen Thompson | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Aug 9, 2022 |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| South Marin Health & Wellness Center 1220 South Eliseo Drive, Greenbrae, CA 94904 CCN 055093 | 72 | Jan 23, 2026 | 57 | — | |
| Berkley West Healthcare Center 1623 Arizona Avenue, Santa Monica, CA 90404 CCN 055136 | 54 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Magnolia Gardens Convalescent Hospital 17922 San Fernando Mission Rd, Granada Hills, CA 91344 CCN 0551421 state class AA/A | 1.6 km | 99 | Jul 21, 2026 | 90 | — | |
| Casitas Care Center 10626 Balboa Blvd., Granada Hills, CA 91344 CCN 056148 | 1.9 km | 99 | Aug 19, 2026 | 76 | — | |
| Rinaldi Convalescent Hospital 16553 Rinaldi St, Granada Hills, CA 91344 CCN 0559063 state class AA/A | 3.7 km | 99 | Aug 12, 2026 | 841 IJ1 harm6 open | — | |
| Granada Hills Convalescent 16123 Chatsworth Ave, Granada Hills, CA 91344 CCN 0561681 state class AA/A | 3.8 km | 48 | Nov 18, 2025 | 461 harm | — | |
| The Rehabilitation Center of North Hills 9655 Sepulveda Boulevard, North Hills, CA 91343 CCN 0563674 state class AA/A | 4.8 km | 138 | Jul 30, 2026 | 1141 harm1 open | $103k | |
| Northridge Care Center 7836 Reseda Blvd, Reseda, CA 91335 CCN 0564122 state class AA/A | 5.3 km | 97 | Aug 31, 2026 | 1191 harm | — | |
| Providence Holy Cross Med Ctr D/P SNF 11600a Indian Hills Road, Mission Hills, CA 91345 CCN 5550741 state class AA/A | 6.1 km | 48 | Mar 27, 2026 | 522 IJ2 harm | $98k | |
| Ararat Nursing Facility 15099 Mission Hills Road, Mission Hills, CA 91345 CCN 5555794 state class AA/ASFF CandidateAbuse icon | 6.1 km | 254 | Jul 24, 2026 | 1555 IJ9 harm | $427k |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 555791 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 555791 | 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 | 920000310 | 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
| Administration |
| $3,000 |
Closed |
| 920019262 |
| May 17, 2023 violation Feb 1, 2023 | Class A | Citation Citation A (HSC 1424) | Patient Care | $75,000 initial $25,000 | Closed | 920018760 |
| Sep 16, 2022 violation Jun 14, 2022 | Class A | Citation Citation A (HSC 1424) | Patient Care | $25,000 | Appealed Open | 920017999 |
| Jul 15, 2021 violation Oct 1, 2019 | AP NHPPD | Administrative Penalty AP - 3.2 Nursing-Hours-per-Patient-Day AP (HSC 1276.5) | DHPPD: 1 Day (No Penalty) | $0 | Open | 810016734 |
| Sep 29, 2017 violation Aug 24, 2017 | Class A | Citation Citation A (HSC 1424) | Patient Care | $15,000 | Closed | 920013490 |
| Aug 25, 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 | No plan of correction | Complaint |
| Aug 25, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | No plan of correction | Complaint |
| Aug 24, 2026 | 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 Sep 18, 2026 | Complaint |
| Aug 24, 2026 | 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 Sep 18, 2026 | Complaint |
| Aug 18, 2026 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 10, 2026 | Complaint |
| Aug 18, 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 Sep 10, 2026 | Complaint |
| Aug 18, 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 Sep 10, 2026 | Complaint |
| Aug 6, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Aug 26, 2026 | Complaint |
| Jul 17, 2026 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 6, 2026 |
| Jul 17, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 6, 2026 |
| Jul 17, 2026 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 6, 2026 |
| Jul 17, 2026 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 6, 2026 |
| Jul 17, 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 Aug 17, 2026 |
| Jul 17, 2026 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 17, 2026 |
| Jul 17, 2026 | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 17, 2026 |
| Jul 17, 2026 | F-0604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Aug 17, 2026 |
| Jul 17, 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 Aug 17, 2026 |
| Jul 17, 2026 | F-0628 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 17, 2026 |
| Jul 17, 2026 | 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, 2026 |
| Jul 17, 2026 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Aug 17, 2026 |
| 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 | D · Potential harm Isolated | Corrected Aug 17, 2026 |
| Jul 17, 2026 | 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 Aug 17, 2026 |
| Jul 17, 2026 | F-0700 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Aug 17, 2026 |
| Jul 17, 2026 | 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 | E · Potential harm Pattern | Corrected Aug 17, 2026 |
| Jul 17, 2026 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Aug 17, 2026 |
| Jul 17, 2026 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Aug 17, 2026 |
| Jul 17, 2026 | 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 Aug 17, 2026 |
| Jul 17, 2026 | F-0805 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Aug 17, 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 17, 2026 |
| Jul 17, 2026 | 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 17, 2026 |
| Jul 17, 2026 | F-0881 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Aug 17, 2026 |
| Jul 17, 2026 | F-0887 | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Aug 17, 2026 |
| Jul 17, 2026 | F-0909 | Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 17, 2026 |
| Jul 10, 2026 | F-0555 | Honor the resident's right to choose his or her attending physician. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jul 29, 2026 | Complaint |
| Dec 16, 2025 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jan 5, 2026 | Complaint |
| May 11, 2025 | 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 10, 2025 |
| May 11, 2025 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 10, 2025 |
| May 11, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 10, 2025 |
| May 11, 2025 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 10, 2025 |
| May 11, 2025 | 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 Jun 10, 2025 |
| May 11, 2025 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 10, 2025 |
| May 11, 2025 | K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 10, 2025 |
| May 11, 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 May 29, 2025 | IDR |
| May 11, 2025 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 29, 2025 | IDR |
| May 11, 2025 | F-0578 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 29, 2025 | IDR |
| May 11, 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 May 29, 2025 |
| May 11, 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 May 29, 2025 |
| May 11, 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 May 29, 2025 |
| May 11, 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 29, 2025 |
| May 11, 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 | E · Potential harm Pattern | Corrected May 29, 2025 |
| May 11, 2025 | 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 May 29, 2025 |
| May 11, 2025 | 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 May 29, 2025 |
| May 11, 2025 | 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 May 29, 2025 |
| May 11, 2025 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected May 29, 2025 |
| May 11, 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 | D · Potential harm Isolated | Corrected May 29, 2025 |
| May 11, 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 | D · Potential harm Isolated | Corrected May 29, 2025 |
| May 11, 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 | E · Potential harm Pattern | Corrected May 29, 2025 |
| Jan 23, 2025 | F-0552 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Feb 5, 2025 | Complaint |
| Jan 23, 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 Feb 5, 2025 | Complaint |
| Sep 23, 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 Oct 11, 2024 | Complaint |
| Sep 23, 2024 | 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 Oct 11, 2024 | Complaint |
| Sep 23, 2024 | 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 Oct 11, 2024 | Complaint |
| Sep 23, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Oct 11, 2024 | Complaint |
| Jun 5, 2024 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 28, 2024 |
| Jun 5, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 28, 2024 |
| Jun 5, 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 28, 2024 |
| Jun 5, 2024 | F-0578 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 28, 2024 |
| Jun 5, 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 | E · Potential harm Pattern | Corrected Jun 28, 2024 |
| Jun 5, 2024 | 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 Jun 28, 2024 |
| Jun 5, 2024 | 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 Jun 28, 2024 |
| Jun 5, 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 28, 2024 |
| Jun 5, 2024 | 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 Jun 28, 2024 |
| Jun 5, 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 28, 2024 |
| Jun 5, 2024 | F-0700 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 28, 2024 |
| Jun 5, 2024 | 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 | D · Potential harm Isolated | Corrected Jun 28, 2024 |
| Jun 5, 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 Jun 28, 2024 |
| Jun 5, 2024 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Jun 28, 2024 |
| Jun 5, 2024 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jun 28, 2024 |
| Jun 5, 2024 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Jun 28, 2024 |
| Jun 5, 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 28, 2024 |
| Jun 5, 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 28, 2024 |
| Jun 5, 2024 | 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 Jun 28, 2024 |
| Jun 5, 2024 | F-0847 | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Jun 28, 2024 |
| Jun 5, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jun 28, 2024 | Complaint |
| Jun 5, 2024 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | B · Minimal Pattern | Corrected Jun 28, 2024 |
| May 1, 2024 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 15, 2024 | Complaint |
| May 1, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected May 15, 2024 | Complaint |
| Feb 27, 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 21, 2024 | Complaint |
| Feb 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 Feb 9, 2024 | Complaint |
| Feb 5, 2024 | F-0770 | Provide timely, quality laboratory services/tests to meet the needs of residents. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Feb 9, 2024 | Complaint |
| Jan 16, 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 Feb 9, 2024 | Complaint |
| Jan 16, 2024 | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 9, 2024 | Complaint |
| Jan 16, 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 16, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Feb 9, 2024 | Complaint |
| Dec 29, 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 | D · Potential harm Isolated | Corrected Jan 12, 2024 | Complaint |
| Dec 29, 2023 | 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 Jan 12, 2024 | Complaint |
| Dec 29, 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 | D · Potential harm Isolated | Corrected Jan 12, 2024 | Complaint |
| Nov 30, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Dec 18, 2023 | Complaint |
| Nov 16, 2023 | 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 Dec 7, 2023 | Complaint |
| Nov 16, 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 Dec 7, 2023 | Complaint |
| Nov 16, 2023 | 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 | D · Potential harm Isolated | Corrected Dec 7, 2023 | Complaint |
| Nov 7, 2023 | F-0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 6, 2023 | Complaint |
| Nov 7, 2023 | F-0624 | Prepare residents for a safe transfer or discharge from the nursing home. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 6, 2023 | Complaint |
| Nov 7, 2023 | 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 Dec 6, 2023 | Complaint |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 3.60 (case-mix index 2.01).
| Keith Vogel | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 28, 2023 |
| Aspen Healthcare Services LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Aug 9, 2022 |
| East West Bank | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Sep 12, 2023 |
| Jacaranda Healthcare Group LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Aug 9, 2022 |
| Moss Adams LLP | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Sep 12, 2023 |
| Wells Fargo Bank, National Association | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Sep 12, 2023 |
| Jeffrey Bradshaw | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Aug 9, 2022 |
| Mark Gobrial | Individual | Additional disclosable party | ADP OF THE SNF | not provided | May 19, 2025 |
| Keith Vogel | Individual | Additional disclosable party | ADP OF THE SNF | not provided | May 19, 2025 |
| Jun 25, 2026 |
841 IJ |
| $101k |
| Ocean Pointe Healthcare Center 1330 17th Street, Santa Monica, CA 90404 CCN 0551551 state class AA/A | 72 | Jun 5, 2026 | 791 IJ | $55k |
| Woodlands Healthcare Center 14966 Terreno De Flores Lane, Los Gatos, CA 95032 CCN 0555172 state class AA/A | 65 | Sep 19, 2025 | 60 | — |
| Stonebrook Health and Rehabilitation 350 De Soto Drive, Los Gatos, CA 95032 CCN 0558002 state class AA/A | 73 | Mar 5, 2026 | 49 | — |
| The Avenues Transitional Care Center 2043 19th Avenue, San Francisco, CA 94116 CCN 055963 | 140 | Oct 2, 2025 | 461 harm | $13k |
| Petaluma Post-Acute Rehabilitation 1115 B Street, Petaluma, CA 94952 CCN 0560722 state class AA/A | 90 | Dec 19, 2025 | 36 | — |
| Cottonwood Healthcare Center 625 Cottonwood Street, Woodland, CA 95695 CCN 0560982 state class AA/A | 98 | Jul 24, 2026 | 50 | — |