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Alameda Hospital D/P SNF

2070 Clinton Ave, Alameda, CA 94501 · Government - County · 181 certified beds · (510) 814-4049 Medicare & Medicaid certified

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Flagged for abuse
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2025
  • a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • nursing-staff turnover (86%) runs well above the national median (45%)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2070 Clinton Ave · (510) 748-0931 · Call to confirm hours
Pharmacy
2314 Santa Clara Ave · (800) 746-7287 · Call to confirm hours
Grocery
Safeway0.3 mi
2227 S Shore Ctr · (510) 863-9000 · Call to confirm hours
Park
Otis Dr · (510) 747-7400 · Typically dawn to dusk
Place of worship
2164 Central Ave · (510) 522-5110

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.6%10.2%15.4%better
Long-stay residents who lose too much weight2.7%4.0%5.4%better
Long-stay residents with a catheter left in their bladder0.3%0.8%0.9%better
Long-stay residents with a urinary tract infection0.2%1.2%2.0%better
Long-stay residents with depressive symptoms0.2%7.3%6.5%better
Long-stay residents who were physically restrained0.8%0.4%0.1%worse than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.9%1.6%3.3%better than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened9.1%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication4.5%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine98.8%98.2%95.3%typical
Long-stay residents with pressure ulcers4.7%4.3%4.7%typical
Long-stay residents with worsening bladder/bowel control4.6%10.2%21.2%better than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table6.7%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine82.5%93.2%79.4%typical
Long-stay hospitalizations per 1,000 resident days1.712.251.67typical
Long-stay outpatient ER visits per 1,000 resident days2.091.571.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

0.20U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 22% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.46
RN hours/ resident / day
0.88
LPN hours/ resident / day
2.77
Aide hours/ resident / day
5.11
Total nurse hours/ resident / day
1.18
RN hoursweekends
86.5%
Total nursing turnover
85.7%
RN turnover

How full it usually is: this home is certified for 181 beds and averages 170.2 residents a day — about 94% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.11 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.46 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.77 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.66 hrs/resident/day on weekends vs 5.29 on weekdays — 12% thinner on weekends. RN hours go from 1.58 to 1.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 86% is well above the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

3
deficiencies at the latest standard inspection (2024-09-19)
6
at the previous standard inspection (2022-08-25)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.

  • Potential for harm · D2026-05-21 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) received services in the facility with reasonable accommodation of resident needs when Resident 1's Active Order for skin care precautions indicating foot cradle (a supportive frame placed at the end or side of a mattress to elevate bed linens and to keep blankets/bedclothes away from the feet or legs of the user) use was not put in place. This deficient practice resulted in Resident 1 not receiving the needed care, assistive device, and/or service as ordered.A review of Resident 1's Inpatient Information, printed on 5/19/26, indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses that included dementia (memory loss), Cerebrovascular Accident (CVA, a stroke), and hemiplegia (muscle weakness on one side of the body, complete paralysis). A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care), dated 12/24/25, indicated Resident 1 was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-25 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to protect one of three sampled residents, (Resident 1), from physical and emotional abuse when Resident 2 punched Resident 1 in the face twice with his fist and put him in a choke hold.This failure resulted in Resident 1 having a contusion (an area of skin discoloration caused by broken blood vessels under the skin, which happens when soft tissue is damaged by an impact), on Resident 1's face requiring transfer to an acute care hospital. Resident 1 stated he was fearful of Resident 2 and did not feel safe at the facility.During a review of Resident 1's admission Record, printed on 11/25/25, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of anxiety (excessive worry, racing thoughts and feeling of impending danger that is uncontrollable and interferes with daily life) and dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-21 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three residents (Resident 1) were free from sexual abuse when Resident 2 sexually abused Resident 1 who had severe intellectual disability and was unable to provide consent. This failure resulted in Resident 1 ' s elbow pain from being held down during the sexual abuse and had the potential for serious physical and psychosocial injury. Findings: A record review of Resident 1 ' s admission record indicated Resident 1 was admitted with severe intellectual disability, weakness, schizophrenia (psychiatric disease which causes distrust of information and other people) and developmental delay. The record further indicated Resident 1 ' s family had conservatorship over them. During a record review of Resident 1 ' s minimum data set (MDS, an assessment tool to guide resident care), dated 11/12/24, the MDS indicated Resident 1 used a wheelchair for mobility and required supervision for bed mobility and had a Brief Interview for Mental…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-19 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure discontinued medications were discarded when they were kept with ready to use medications in medication refrigerator. This failure had the potential to result in residents receiving the medication erroneously, which could lead to new health problems or adverse reactions. Findings: During an observation and interview on 09/18/24, at 11:47 a.m., with Registered Nurse (RN) 1, in the Nursing Station, the medication refrigerator was observed to have the following discontinued medications: -Admelog 100 unit (u)/milliliter (ml) (medication used for high blood sugar) for Resident 29. -Lantus 100 u/ml (medication used for high blood sugar) for Resident 100. -Lantus 100 u/ml (medication used for high blood sugar) for Resident 147. -Basaglar 100 u/ml Kwikpen (3 pens) (medication used for high blood sugar) for Resident 18. RN 1 stated she remembered Residents 100, 29 and 18 had not received insulin for some time and had either transitioned to oral medications to control their blood sugar or the medication was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-19 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility had 11 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) with multiple beds that provide less than 80 square feet (sq. ft.) per resident who occupy these rooms. This failure had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of the residents' belongings. Findings: During observations of care and services from 9/16/24 through 9/19/24, the following rooms and corresponding square footage per bed were identified: 1. room [ROOM NUMBER] had two beds, total sq. ft. is 154 and 77 sq. ft. per bed. 2. room [ROOM NUMBER] had two beds, total sq. ft. is 154 and 77 sq. ft. per bed. 3. room [ROOM NUMBER] had two beds, total sq. ft. is 154 and 77 sq. ft. per bed. 4. room [ROOM NUMBER] had two beds, total sq. ft. is 154 and 77 sq. ft. per bed. 5. room [ROOM NUMBER] had four beds, total sq. ft. is 287 and 71.75 sq. ft. per bed. 6. room [ROOM NUMBER] had four beds, total sq. ft. is…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-19 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure infection control practices were implemented when one of four residents, Resident 21's bedside commode (a portable toilet) was visibly soiled. This failure placed the facility's residents at risk for healthcare-associated infections. Findings: During a review of Resident 21's admission Record, dated 9/18/24, the admission Record indicated Resident 21 was admitted to the facility on [DATE]. During a record review of Resident 21's Minimum Data Set (MDS- An assessment tool to guide care), dated 7/24/24, MDS indicated Resident 21 required supervision when walking from room to room and when performing toilet hygiene. The MDS indicated Resident 21 had an active diagnosis of Non-Alzheimer's Dementia (memory loss). During an observation on 9/16/24, at 12:41 p.m., in Resident 21's room, Resident 21 was sitting on the side of her bed eating lunch with her lunch tray on top of her bedside table. Resident 21's bedside table was positioned…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-08-25 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards of food and safety when: 1. The food preparation area was adjacent to the hand wash station/sink with inadequate protection from potential splashes of contaminated water and soap from handwashing. 2. The ready-to-use pans stored above the food preparation area were wet. 3. Dietary Clerk (DC) did not cover hair completely while in the kitchen and during tray-line. These failures had the potential to result in food-borne illnesses. Findings: 1. During an observation and concurrent interview on 8/22/22 at 10 a.m., with Assistant Director of Food and Nutrition (ADFN), in the kitchen, the food preparation area had a tray of chopped raw vegetables being prepared for lunch service. The chopped vegetable tray was approximately five inches away from a splash guard which separated the food preparation area from a handwashing sink. The length of the chopped vegetable tray extended beyond the edge of the splash guard for over six inches. There…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-25 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one (Resident 3) of three sampled discharged residents, the facility failed to complete and transmit Minimum Data Set (MDS, an assessment tool used to direct resident care) within 14 days of discharge from the facility. The failure to complete and transmit the Discharge Assessment for five months and 25 days after Resident 3 transferred to the acute care hospital and did not return, resulted in lack of tracking of residents leaving the facility. Findings: A review of Resident 3's annual MDS dated [DATE], indicated Resident 3 had been in the facility for more than three years with a current diagnosis of respiratory failure (impaired breathing function). A review of Resident 3's progress notes dated 4/21/22, indicated Resident 3 was unresponsive, pulseless, and was transferred to the hospital. During an interview and concurrent record review on 8/25/22 at 10:51 a.m., with the Director of Nursing (DON), Resident 3's MDS records were reviewed. The DON stated the annual…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-25 · tag F0726 — failed to have competent, trained nursing staff — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure two Certified Nursing Assistants (CNA 2 and CNA 3) demonstrated competency in skills and techniques for provision of resident care according to resident care plans. The failure to ensure CNA 2 and CNA 3 completed annual performance and competency appraisals had the potential to result in inadequate or improper care for the CNAs assigned residents. Findings: During a record review and concurrent interview on 8/24/22 at 11:47 a.m., with the Supervisor for HR Service and Compliance (SHRSC) the personnel files of CNA 2 and CNA 3 were reviewed. SHRSC stated CNA 3 had a hire date in January of 2019 and should have had an annual performance review in January of 2022, but CNA had not had a performance review this year. SHRSC stated CNA 2 had a hire date in August of 2008 but had not a performance evaluation completed since 2020. A review of the policy titled, Performance Appraisal, revised date 5/2020, the policy indicated the purpose of the performance appraisal was: To establish communication, focused on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-25 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and document reviews the facility failed to be free of medication error rates of five percent or greater when three medication errors were observed out of 28 opportunities. The medication error rate was calculated as follows: three divided by 28 then multiplied by 100, which was equal to 10 percent. This failure had the potential to result in ineffective medication regimen for the effected residents (Residents 104, 117, and 125). Findings: 1. A review on 8/23/22 of the manufacturers insert for Advair HFA (fluticasone/salmeterol-medication used for Asthma) indicated, INSTRUCTIONS FOR USE ADVAIR HFA .How to use your ADVAIR HFA inhaler Follow these steps every time you use ADVAIR HFA .Step 3. Breathe out through your mouth and push as much air from your lungs as you can .Step 7. Rinse your mouth with water after breathing in the medicine. Spit out the water. Do not swallow it . During an observation on 8/23/22 at 8:15 a.m., Licensed Vocational Nurse 1 (LVN 1) did not instruct Resident 104 to breathe out as much air as possible prior to the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 6 citations
  • Potential for harm · Dcited before2022-08-25 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure one employee (Certified Nursing Assistant 1, CNA 1) wore required personal protective equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury) and performed required hand hygiene after providing direct care to a resident in a room on contact, droplet, and airborne precautions. (Contact and droplet precautions are actions implemented to prevent the spread of infection based upon the transmission mode of direct or indirect contact with respiratory secretions from the resident or environmental surfaces contaminated with respiratory secretions. Airborne precautions are actions taken to prevent or minimize the transmission of infectious agents/organisms that remain infectious over long distances when suspended in the air.) The failure to wear a gown and gloves and to perform hand hygiene after direct care and before exiting from a room with a resident in isolation for exposure to COVID-19 (a contagious respiratory disease that can result in…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-06-19 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, and record review, the facility failed to ensure food was prepared under sanitary conditions when: a. a manual can opener had metal shavings on the blade, and; b. Dietary Aide 2 rinsed the peeled boiled eggs in the 3 compartment sink. These failures had the potential to result in food contamination and food-borne illness. Findings: a. During an observation and concurrent interview on 6/17/19, at 9 a.m., in the presence of the Regional Director of Dietary and the Dietary Manager, the facility's manual can opener had metal shavings on the blade and on the inner portion of the device. The Regional Director of Dietary stated the canopener should have been cleaned before use. Review of the facility's Cleaning Procedures for Can Opener Policy & Procedure (not dated), indicated instructions for the dietary staff to clean the can opener before and after using the equipment. 2. During observation on 6/18/19, at 10:54 a.m. Dietary Aide 2 peeled boiled eggs and rinsed them in the rinse sink of the three compartment sink (used for washing, rinsing and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-06-19 · tag F0802 — failed to prepare enough nourishing food — isolated
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure staff competency when Dietary Aide 1: a. used a sanitizing agent test strip not intended for use with the Quat sanitizer (anti-microbial agent) solution to test the Quat sanitizer solution concentration, and; b. immersed a newly washed blender in the sanitizing sink for a few seconds. This failure had the potential to result in food-borne illness. Findings: During an observation on 6/17/19, at 9:35 a.m., Dietary Aide 1 used a test strip not intended for use with the Quat Sanitizer to check the Quat sanitizer solution concentration in the three compartment sink. During an interview on 6/17/19, at 9:35 a.m., Food Service Director stated it was not the right strip and told Dietary Aide 1 to use another test strip while pointing to the Quat Sanitizer Test Strips. In an observation on 6/17/19, at 9:35 a.m., Dietary Aide 1 washed the blender on the 3 compartment sink (for washing, rinsing, and sanitizing dishes) and immersed it on the 3rd sink for few seconds to be sanitized. During an interview on 6/17/19,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-06-19 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to follow infection control practices for one (Resident 421) of 34 sampled residents when Registered Nurse (RN) 2 did not perform hand hygiene (wash hands with soap and water or use an alcohol based hand rub) during wound care. This deficient practice did not ensure effective control and prevention of the spread of infection in the facility. Findings: Review of Resident 421's admission Face Sheet, dated 6/13/19, indicated Resident 421 was admitted to the facility with multiple diagnoses that included pressure ulcer (tissue damage caused by staying in the same position for too long) and anemia (condition in which the blood does not have enough properly functioning red blood cells potentially resulting in slower wound healing and wound infections). Review of Resident 421's Weekly Pressure Ulcer BWAT Report, dated 6/12/19, indicated Resident 421 had a 0.7 cm by 1.2 cm stage 2 pressure (shallow open sore) to the sacral/coccygeal (lower back) region. During an observation on 6/19/19, at 10:14 a.m., RN 2 provided wound…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2022-08-25 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the South Shore facility had 11 rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) with multiple beds that provided less than 80 square feet (sq.ft.) per resident who occupied these rooms. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for storage of resident belongings. Findings: During an observation on 8/24/22 at 10:00 a.m., with the Operations Manager (OP),the following resident rooms and corresponding square footage (sq.ft.) were identified: Room- Activity- Room- Size- Floor Area 1 Res Room- 2 bedroom [ROOM NUMBER] sq.ft. 77 sq.ft. 2 Res Room- 2 bedroom [ROOM NUMBER] sq.ft. 77 sq.ft. 3 Res Room- 2 bedroom [ROOM NUMBER] sq.ft. 77 sq.ft. 4 Res Room- 2 bedroom [ROOM NUMBER] sq.ft. 77 sq.ft. 5 Res Room- 4 bedroom [ROOM NUMBER] sq.ft. 71.75 sq.ft. 6 Res Room- 4 bedroom [ROOM NUMBER].5 sq.ft. 70.88 sq.ft. 7 Res Room- 2 bedroom [ROOM NUMBER].88 sq.ft. 77.45 sq.ft. 8 Res…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2019-06-19 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility had 11 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) with multiple beds that provided less than 80 square feet (sq.ft.) per resident (Rt) who occupied these rooms. This failure had the potential to result in a lack of adequate space for the provision of resident care by the facility staff and for the lack of sufficient space for resident's belongings. Findings: During an observation on 6/19/19 at 10:38 a.m., with Engineer, the following resident rooms and corresponding square footage (sq.ft.) were identified: Room Activity Room Size Floor Area 1 Rt Room 154 sq.ft. 77 sq.ft. 2 Rt Room 154 sq.ft. 77 sq.ft. 3 Rt Room 154 sq.ft. 77 sq.ft. 4 Rt Room 154 sq.ft. 77 sq.ft. 5 Rt Room 287 sq.ft. 71.75 sq.ft. 6 Rt Room 283.5 sq.ft. 70.88 sq.ft. 7 Rt Room 154.88 sq.ft. 77.45 sq.ft. 8 Rt Room 154.88 sq.ft. 77.45 sq.ft. 9 Rt Room 156.69 sq.ft. 78.34 sq.ft. 10 Rt room [ROOM NUMBER].22 sq.ft. 74.65 sq.ft. 11 Rt Room 149.77 sq.ft. 74.88 sq.ft. During random…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Waiver has been granted

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
JOHNSON, SHARIIndividualDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/20/2024
SHARMA, NAINIIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2019
FINLEY, DELVECCHIOIndividualCORPORATE OFFICERsince 08/31/2015
LOWERY, WILLIAMIndividualCORPORATE OFFICER; ADP OF THE SNFsince 01/01/2019
ALAMEDA HEALTH SYSTEMOrganizationOPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNFsince 01/28/2025

CMS files one row per role, so the 12 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

What families pay in CA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.

Typical monthly cost in California
$12,167/mo
Nursing home (semi-private)
$15,178/mo
Nursing home (private)
$7,000/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555381. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-09-19, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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