Grace Home Inc.
13435 Peach Avenue, Livingston, CA 95334 · Non profit - Church related · 33 certified beds · (209) 394-2440 Medicaid only — no Medicare
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (16% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 4 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 12.0% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.9% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.2% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.3% | 1.2% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 7.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.1% | 1.6% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 16.7% | 9.8% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 20.2% | 13.7% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.0% | 4.3% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 17.6% | 10.2% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.1% | 12.0% | 17.1% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.42 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.33 | 1.57 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
Staffing
How full it usually is: this home is certified for 33 beds and averages 32.9 residents a day — about 100% occupied, or roughly 0 beds typically open. It runs essentially full — expect a waiting list. 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 4.34 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.25 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.91 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 3.91 hrs/resident/day on weekends vs 4.52 on weekdays — 13% thinner on weekends. RN hours go from 0.25 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 16% is below the national median of 45%.
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
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.
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.
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.
18 citations, most serious first. The 10 most serious are shown; the remaining 8 are one tap away and print in full.
- Potential for harm · Ecited before2026-05-22 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 prepare, distribute and serve food in accordance with professional standards for food service safety when:1. Clear measuring cups had cracks in them.2. Two green and one brown colored cutting boards were observed with deep cuts, scratches and scoring.These failures had the potential to cause cross contamination (the process by which germs are unintentionally transferred from one substance or object to another, with harmful effect) and the growth of microorganisms (a microscopic organism, especially a bacterium, virus, or fungus) that harbor foodborne pathogens (a bacterium, virus, or other microorganism that can cause disease) of residents' food which could lead to food-borne illness (stomach illness acquired from ingesting contaminated food) for the 30 residents admitted to the facility who receive meals from the kitchen.1. During a concurrent observation and interview on 5/21/26 at 11:19 a.m. with the Certified Dietary Manager (CDM) in the kitchen, a set of clear measuring cups was observed with multiple…
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.
- Potential for harm · Fcited before2025-03-07 · tag F0658 — failed to meet professional standards of care — widespreadEnsure services provided by the nursing facility meet professional standards of quality.
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 maintain professional standards of quality for 10 of 32 sampled residents (4, 5, 8, 11, 13, 14, 15, 23, 24, and 28) when: 1. Resident 15 had a specialty mattress (perimeter mattress or raised perimeter mattress refers to a mattress designed with a raised edge or bolster [a long pillow or cushion] along the sides to prevent falls) on her bed without a physician order or care plan in place. This failure of not having a physician order or implementing a comprehensive care plan for Resident 15 had the potential to place Resident 15's safety at risk and her specific needs not being met. 2. The facility failed to obtain a physician order for a specialty mattress for one of six sampled residents (Resident 4) when a pressure reducing mattress was replaced with a perimeter mattress. This failure had the potential to place Resident 4's safety at risk and their specific needs not being met 3. Licensed Vocational Nurse (LVN) 2 and LVN 3 used only one…
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.
- Potential for harm · F2025-03-07 · tag F0727 — failed to provide required RN coverage — widespreadHave 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to have a Registered Nurse (RN) in the facility at least 8 consecutive hours in a day. This failure had the potential to put Residents' safety at risk and their specific needs not being met. Findings: During an interview on 3/5/25 at 11:55 p.m., with the Director of Staff Development (DSD), the DSD stated she was covering for the Director of Nursing because he left at 11 a.m. The DSD stated she was a Licensed Vocational Nurse and not an RN. During an observation on 3/5/25 at 4:30 p.m., while walking throughout the entire facility, there appeared to be no RN currently in the building. During an interview on 3/5/25 at 5:15 p.m., with the Administrator (ADM), the ADM stated there was not an RN currently in the building. The ADM stated the only RN that was working for the day was the Director of Nursing (DON) who left at 11 a.m. due to scheduled time off. The ADM stated he was unaware that an RN had to be in the facility for eight consecutive hours at a time. The ADM stated the facility did not have a waiver regarding the RN not…
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.
- Potential for harm · Fcited before2025-03-07 · tag F0761 — failed to label and store drugs safely — widespreadEnsure 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.
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 safe and secure storage of medications when: 1. Medication room was propped open and unattended by authorized staff. This failure had the potential to place facility at risk for unauthorized access to medication room and possible drug diversion. 2. Resident 5's Hydrocortisone 2.5% topical cream was beyond the discard date. This failure had the potential for residents to receive expired medications that were no longer effective. Findings: 1. During an observation on 3/4/25 at 12:45 p.m. at the nursing station, the medication storage room at the nursing station was propped open and unattended. There was no staff inside the medication storage room and no staff sitting at the nursing station. During an interview on 3/4/25 at 2:30 p.m., with Licensed Vocational Nurse (LVN) 2, at the nursing station, LVN 2 stated medication room was wide open and unattended earlier. LVN 2 stated medication room should always be kept locked to prevent residents and unauthorized personnel access to medications. During an…
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.
- Potential for harm · Fcited before2025-03-07 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 label stored food and properly clean the kitchen for 31 of 33 Residents (Resident 1, 2, 3, 5, 6, 7, 8, 9, 10, 12, 13, 14,15,16, 17, 18, 19, 20, 21, 22, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33) who eat food from the facility when: 1. Pastrami was not labeled with a thaw date after being moved from the freezer to the refrigerator. 2. The quaternary ammonium sanitizer solution used to clean the food preparation surfaces after breakfast tested at 150 ppm (parts per million), below the targeted 200-400 ppm. 3. Staff failed to document the dishwashing machine temperature log, prior to the start of washing, at each meal, to ensure proper sanitation of all dishware and trays. These failures had the potential to result in cross contamination (the unintentional transfer of harmful bacteria or other contaminants from one food, surface, or object to another, often leading to foodborne illnesses) and the growth of microorganisms which could lead to food borne illness for 31 of 33 residents admitted to the facility who…
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.
- Potential for harm · E2025-03-07 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 review and revise a comprehensive care plans for four of 12 residents (Resident 1, 4, 7 and 11) when: 1. Resident 1's Care Plan did not identify oxygen treatment interventions when oxygen was ordered by the physician. 2. Resident 4's mattress was changed to a specialty perimeter mattress and the care plan did not reflect this change. 3. Resident 7 was reassigned to another room after Resident 7's spouse passed away on 9/25/24. 4. Resident 11's care plan did not reflect assessment and interventions to address a change of condition in which Resident 11 was no longer able to ambulate (walk) without assistance. . These failures had the potential to result in Residents 1,4,7, and 11 not to receive necessary care and services by nursing staff and to delay the provision of timely individualized physical and psychosocial person-centered care . Findings: 1. During a concurrent observation and interview on 3/4/25 at 11:01 a.m. with Resident 1 in 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.
- Potential for harm · E2025-03-07 · tag F0803 — failed to meet residents' dietary needs — patternEnsure 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.
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 the pureed turkey recipe for four of 31 sampled residents' (Resident 11, 14, 15, and 20) on a pureed (smooth textured food without lumps that does not require chewing, holds shape on a spoon and is not sticky) diet when water was substituted for turkey or chicken stock. This failure had the potential to decrease the food's flavor and nutritive value (providing and containing the nourishment needed for growth, health, and well-being) for all four residents on a pureed diet, and could have led to decreased intake and unexpected weight loss, which may further compromise their medical status. Findings: During a concurrent observation and interview on 3/5/25 at 10:56 a.m. with the cook (COOK) 1 in the kitchen, COOK 1 prepared pureed turkey for lunch. COOK 1 pureed cooked turkey roast with water, instead of turkey or chicken stock, in the blender. COOK 1 stated it was important to follow the recipe to ensure the food tastes good and a pudding like texture was achieved. During a phone interview on 3/6/25 at…
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.
- Potential for harm · Ecited before2025-03-07 · tag F0880 — failed to prevent and control infections — patternProvide 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 follow it's own infection prevention program designed to provide a safe and sanitary environment for three of eleven sampled residents when: 1. Resident 29 and Resident 31's urinals were hanging inside their trash can at bedside. 2. LVN 2 did not perform cleaning of Resident 13's inhaler and bedside table when Resident 13's inhaler was placed on top of bedside table before and after use. These failures had the potential risk in the development and transmission of communicable diseases and infections for Residents 13, 29, and 31. Findings: 1. During an observation on 3/4/25 at 4:20 p.m. in room [ROOM NUMBER], Resident 29 and Resident 31's urinals were hanging inside their trashs can at bedside. Resident 29 and Resident 31 were sitting in wheelchairs beside their beds. During a concurrent observation and interview on 3/4/25 at 4:23 p.m. with Resident 31, in Resident 31's room, Resident 31 was sitting in his wheelchair. Resident 31 was alert…
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.
- Potential for harm · Ecited before2025-03-07 · tag F0912 — patternProvide 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 staff interview during the survey period from 3/4/25 through 3/7/25, the facility failed to ensure each bedroom had 80 square feet of usable living space for residents in three of 14 rooms (room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]). This failure to provide the residents in rooms 4, 6 and 7 with 80 square feet of space had the potential for the residents to not have enough space to accommodate their personal needs and belongings. Findings: During an interview on 3/7/25 at 10:15 a.m., with the Administrator (ADM), the ADM stated he was aware room [ROOM NUMBER], 6, and 7 did not meet the minimum space requirement for two residents. The ADM provided the room measurements for rooms 4, 6 and 7. The room measurements were as follows: Room Number: Number of Beds/Residents: Square Footage per Resident: 4 2 153.12 square feet (sq ft- unit of measurement: 76.56 sq ft per resident) 6 2 152.1 sq ft (76.05 sq ft per resident) 7 2 152.1 sq ft (76.05 sq ft per resident) During an…
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.
- Potential for harm · D2025-03-07 · tag F0641 — isolatedEnsure each resident receives an accurate 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 observation, interview, and record review, the facility failed to ensure an accurate assessment was reflective of the resident's status for 1 of 1 sampled residents when Resident 24's diagnosis of hip fracture was not recorded in Minimum Date Set (MDS) Section I. This failure had the potential for Resident 24 not to receive necessary care and services by nursing staff and put Resident 24 at risk of injury. Findings: During a concurrent observation and interview on 3/4/25 at 11:33 a.m. with Resident 24, at the hallway in-front of the nursing station, Resident 24 was sitting in her wheelchair with a boot on her right foot. Resident 24 was alert, oriented to her name only, and pleasantly confused. Resident 24 stated she sprained (a stretching or tearing of ligaments) her foot yesterday, with a smile on her face. During a review of Resident 24's admission Record (AR), dated 3/6/25, the AR indicated, Resident 24 has a primary diagnosis of Parkinson's Disease (a disorder of the central nervous system that…
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.
Show the remaining 8 citations
- Potential for harm · D2025-03-07 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 develop and implement a comprehensive person-centered care plan for one of 12 residents (Resident 15), when Resident 15 had a specialty mattress (perimeter mattress or raised perimeter mattress refers to a mattress designed with a raised edge or bolster [a long pillow or cushion] along the sides to prevent falls) on her bed without a care plan in place. This failure of not implementing an individualized care plan for Resident 15 had the potential to place Resident 15's safety at risk and her specific needs not being met. Findings: During a review of Resident 15's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 3/7/25, the admission Record indicated, Resident 15 was admitted to the facility on [DATE] with a diagnosis of unspecified disorder of psychological…
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.
- Potential for harm · Fcited before2024-03-01 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 safe and sanitary food preparation practices were followed in the kitchen when there was no air gap (a space provided to prevent unsanitary water from flowing back into the sink) under the three-compartment food preparation sink. This failure placed 32 of 32 residents at risk for food contamination and foodborne illness. Findings: During a concurrent observation and interview on 2/28/24 at 11:37 a.m., with Dietary Aid (DA)1, in the kitchen, DA 1 stated food was prepared in the three-compartment sink. The food was prepared in the third compartment and the garbage disposal was also in the third compartment. During a concurrent observation and interview on 2/29/24 at 11:30 a.m., with the Certified Dietary Manager (CDM), in the kitchen, there was no air gap under the three-compartment food preparation sink. The CDM stated, the three-compartment food preparation sink required an air gap to meet federal guidelines. During a concurrent interview and record review on 2/29/24 at 1:00 p.m., with the Director of…
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.
- Potential for harm · Ecited before2024-03-01 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
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 follow professional standards of practice for nine of 16 sampled residents (Resident 3, 7, 9, 11, 13, 20, 28, 31 and 32) when: 1. Resident 13 and Resident 32's medications were administered late. This failure placed Resident 13 at risk for subtherapeutic effects (level too low to produce the intended medical effect) of the medication and Resident 32 at risk for increased anxiety (feeling of fear, dread and uneasiness). 2. Residents 3, 7, 9, 11, 13, 20, 28, 31 and 32 meal trays were served without a Licensed Nurse (LN) verifying the food served was the diet prescribed by the physician. This failure had the potential for residents to receive an incorrect diet and not meeting their nutritional needs. Findings: 1. During a concurrent observation and interview on 2/28/24 at 10:13 a.m., by the resident rooms hallway, Licensed Vocational Nurse (LVN) 1 was preparing resident medications. LVN 1 had the medication administration record (MAR) screen…
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.
- Potential for harm · E2024-03-01 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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, the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards of practice for four of eight sampled residents (Resident 6, 7, 11 and 33) when a copy of the Physician Orders for Life-Sustaining Treatment (POLST) forms (a legal document that specifies the type of care a resident's treatment and services would like in an emergency life threatening medical situation) were incomplete and readily available as part of the residents' medical record. These failures had the potential risk for Residents 6, 7, 11 and 33's end-of-life care decisions to not be followed in case of an emergency. Findings: During a review of Resident 6's admission Record (AR-a document with personal identifiable and medical information), undated, the AR indicated, Resident 6 was admitted to the facility on [DATE] with diagnoses which included hypomagnesemia (low level of magnesium in the blood), anxiety (feeling of fear, dread 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.
- Potential for harm · Ecited before2024-03-01 · tag F0880 — failed to prevent and control infections — patternProvide 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 maintain an effective infection prevention and control program when Licensed Vocational Nurse (LVN) 1 failed to properly disinfect (to clean something in order to destroy bacteria) resident-shared blood pressure (BP) cuffs (a device used to measure blood pressure) prior to and after use on four of eight residents (Resident 11, 32, 20 and 1). This failure placed Residents 11, 32, 20 and 1 at risk for the development and spread of infection. Findings: During an observation on 2/28/24 at 7:45 a.m., in Resident 11's room, LVN 1 checked Resident 11's blood pressure with a reusable wrist BP cuff. LVN 1 walked out of Resident 11's room and placed the soiled BP cuff on top of the medication cart without disinfecting it. During a review of Resident 11's admission Record (AR-a document with person identifiable and medical information), undated, the AR indicated, Resident 11 was admitted to the facility on [DATE] with diagnoses which included…
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.
- Potential for harm · Ecited before2024-03-01 · tag F0912 — patternProvide 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 failed to provide 80 square feet per resident for 3 of 14 rooms (rooms [ROOM NUMBER]) when there were two residents in a room that did not meet the square footage requirement. This failure to provide the residents in rooms 4, 6 and 7 with 80 square feet of space had the potential for the residents to not have enough space to accommodate their personal needs and belongings. Findings: During a concurrent observation and interview on 3/1/24 at 8:40 a.m., with Certified Nursing Assistant (CNA) 1 in room [ROOM NUMBER], there were two beds against opposite walls and a large bedside stand in between the beds. The room also had a closet for additional storage. CNA 1 stated the residents had enough storage space for their belongings and the size of the room did not interfere with care. CNA 1 stated rooms [ROOM NUMBERS] were similar in size to room [ROOM NUMBER] and had 2 residents in each room. CNA 1 stated there was no issue with the storage space 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.
- Potential for harm · D2024-03-01 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 residents were treated with dignity and respect for one of eight sampled residents (Resident 7) when Resident 7's urinary catheter (flexible tube inserted into the bladder to drain urine) bag was not covered and visible to residents and visitors while Resident 7 was in her room. This failure had the potential to violate Resident 7's privacy and dignity. Findings: During an observation on 2/27/24 at 10:20 a.m., in Resident 7's room, Resident 7 was lying in bed with a urinary catheter bag hanging on the bedframe uncovered, facing the door. The uring bag was visible when entering the room and the bag was half full of yellow urine. During a review of Resident 7's admission Record (AR-a document with person identifiable and medical information), undated, the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses which included, Hypo-osmolality (low electrolytes [minerals] in the blood) and hyponatremia (low sodium…
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.
- Potential for harm · Dcited before2024-03-01 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
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 provide safe storage and labeling of medications for one of one medication cart when a a bubble pack of pantoprazole (a medication to help decrease the amount of acid in the stomach) 40 mg (milligrams - unit of measure), with an expiration date of 5/31/23, was found in the medication cart. This failure had the potential to allow use of an expired medication which could compromise the health of the facility residents. Findings: During a concurrent observation, interview, and record review on 2/28/24 at 2:25 p.m. with Licensed Vocational Nurse (LVN) 1, a bubble pack of pantoprazole 40 mg prescribed to Resident 20 was stored in the medication cart and available for use. The pantoprazole, with instructions to give one tablet once daily, had an expiration date of 5/31/23. LVN 1 reviewed Resident 20's physician orders. LVN 1 stated the pantoprazole had been discontinued on 2/8/21. LVN 1 stated expired or discontinued medication should have not been available in the medication cart to prevent administering 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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
What families pay in CA
CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. 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.
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 05A110. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-22, 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.