No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Crestwood Manor

1400 Celeste Dr., Modesto, CA 95355 · For profit - Corporation · 194 certified beds · (209) 526-8050 Medicaid only — no Medicare

Call the home — (209) 526-8050 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0607) — cited Oct 20233 actual-harm citations
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • 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 (31% vs 45% nationally) — better care continuity
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 3 actual-harm citations
  • a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • 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.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1401 Spanos Ct · (209) 521-9661 · Call to confirm hours
Pharmacy
2020 Coffee Rd Ste C2 · (209) 522-3367 · Call to confirm hours
Grocery
2400 Coffee Rd · (209) 572-2194 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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 3 of 5
Long-stay residentspeople who live here 3 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 improved from 4 to 5 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 rating5★
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 increased12.9%10.2%15.4%better
Long-stay residents who lose too much weight2.8%4.0%5.4%better
Long-stay residents with a catheter left in their bladder1.4%0.8%0.9%worse
Long-stay residents with a urinary tract infection2.3%1.2%2.0%worse
Long-stay residents with depressive symptoms1.7%7.3%6.5%better
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.5%1.6%3.3%better than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened11.5%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication28.3%13.7%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers3.9%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control11.8%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 table98.0%12.0%17.1%check this — see note marked dagger below the table
Long-stay hospitalizations per 1,000 resident days1.792.251.67typical
Long-stay outpatient ER visits per 1,000 resident days2.051.571.80worse

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. 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

0.36
RN hours/ resident / day
1.11
LPN hours/ resident / day
2.97
Aide hours/ resident / day
4.44
Total nurse hours/ resident / day
0.22
RN hoursweekends
30.8%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 194 beds and averages 152.4 residents a day — about 79% occupied, or roughly 42 beds typically open. It usually has some room. 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 4.44 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.97 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 3.85 hrs/resident/day on weekends vs 4.68 on weekdays — 18% thinner on weekends. RN hours go from 0.42 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 31% 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

3
deficiencies at the latest standard inspection (2024-08-15)
1
at the previous standard inspection (2019-12-19)

Deficiencies are more than at the previous inspection — worsening. 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.

19 citations, most serious first. The 13 most serious are shown; the remaining 6 are one tap away and print in full.

  • Actual harm · G2025-05-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    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 adequate supervision was provided to prevent accidents for one of three sampled residents (Resident 1) when Resident 1 was assessed to be a high risk for falls and had a history of falls and effective interventions were not implemented to prevent a fall on [DATE]. Resident 1 was assessed to have an unsteady gait, educated on the need to call for assistance, had falls on [DATE], [DATE], [DATE]and fell on [DATE]. On [DATE], Resident 1 went to the bathroom unassisted, staff became aware of her presence in the bathroom alone, did not assist her with toileting, left her alone in the bathroom and Resident 1 fell and injured her right ankle. These failures resulted in Resident 1 not being provided with the level of assistance and supervision needed to prevent a fall, suffered an ankle injury requiring emergency transport to an acute care hospital for care and services and diagnosed with a fracture to the distal fibula [the lower, outer…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-03-26 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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 ensure one of four sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice when Licensed Vocational Nurse (LVN) 1 administered psychoactive (medication that changes brain function and results in alterations in perception, mood, consciousness, cognition [pertaining to reasoning, memory and judgement], or behavior) medications not prescribed to Resident 1 in error. This failure resulted in Resident 1's transfer to the emergency department (ED) and admission to the general acute care hospital (GACH) for decreased mental status and treatment of an accidental overdose (dangerous and excessive dose of a drug). (Cross reference F 726, F 760) Findings: During a concurrent observation and interview on 3/11/24 at 11:39 a.m. with Resident 1 in the dining room, Resident 1 finished her meal, stood without assistance and walked down the hallway. Resident 1's gait (a person's manner of walking)…

    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
  • Actual harm · G2024-03-26 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 four sampled residents (Resident 1) was free of significant medication errors when Licensed Vocational Nurse (LVN) 1 did not correctly identify Resident 1 and administered Resident 4's psychoactive (medication that changes brain function and results in alterations in perception, mood, consciousness, cognition [pertaining to reasoning, memory and judgement], or behavior) medications to her in error. This failure resulted in Resident 1 experiencing a change in mental status which required a transfer to the emergency department (ED) and admission to the general acute care hospital (GACH) for an accidental overdose (dangerous and excessive dose of a drug) of medication. (Cross reference F 658, F 726) Findings: During a concurrent observation and interview on 3/11/24 at 11:39 a.m. with Resident 1 in the dining room, Resident 1 finished her meal, stood without assistance and walked down the hallway. Resident 1's gait (a person's…

    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 · D2024-08-15 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure a written consent was obtained for in-room camera monitoring for 2 (Resident #103 and Resident #124) of 2 sampled residents reviewed for privacy. Findings included: An undated facility document titled, Consent for Identification Photograph, specified, [Facility name] may utilize audio or video recording and telecommunication if face-to-face services are not available and/or if the treatment team determines this to be an appropriate form of communication. A facility policy titled, Resident Rights, revised 10/2012, specified, 11. To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. 1. An admission Record revealed the facility admitted Resident #103 on 10/12/2017. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia and adverse effects of unspecified antipsychotics and neuroleptics. A significant…

    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 before2024-08-15 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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

    Based on observation, interview, record review, and facility policy review, the facility failed to ensure a care plan was implemented for in-room camera monitoring for 2 (Resident #103 and Resident #124) of 2 sampled residents reviewed for privacy. Findings included: A facility policy titled, Care Planning, revised 10/28/2017, specified, Policy A person-centered care plan to meet the individual needs of residents/clients is prepared by an Interdisciplinary Team, which is periodically reviewed and revised after subsequent assessments. 1. An admission Record revealed the facility admitted Resident #103 on 10/12/2017. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia and adverse effects of unspecified antipsychotics and neuroleptics. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/20/2024, revealed Resident #103 had a Staff Assessment for Mental Status (SAMS), which indicated the resident had moderately impaired cognitive skills for daily decision making. The MDS indicated…

    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 · Dcited before2024-08-15 · 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, record review, and facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions when they performed wound care for 1 (Resident #113) of 1 sampled resident reviewed for pressure ulcer/injury. Findings included: A facility policy titled, Enhanced Barrier Precautions, revised 05/21/2024, indicated, 1. Identify residents at high risk for MDRO [multiple-drug resistant organisms] colonization and transmission. Use ESP [Enhanced Standard Precautions], primarily gowns and gloves for specific high contact care activities, based on the resident's characteristics that are associated with a high risk of MDRO colonization and transmission. *Presence of indwelling devices *Wounds or presence of pressure ulcer (unhealed). An admission Record indicated the facility admitted Resident #113 on 02/25/2020. According to the admission Record, the resident had a medical history that included diagnoses of urinary incontinence and non-pressure chronic ulcer of the right ankle. A quarterly Minimum Data Set (MDS), with an Assessment…

    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 · E2024-03-26 · tag F0726 — failed to have competent, trained nursing staff — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure licensed nurses have the specific competencies and skill sets necessary to assure residents maintained their highest practicable physical, mental, and psychosocial well-being when one of three Licensed Vocational Nurses (LVN 1) did not correctly identify one of four sampled residents (Resident 1) during medication administration. This failure resulted in Resident 1 receiving Resident 4's medication and experiencing a change in mental status which required a transfer to the emergency department (ED) and admission to the general acute care hospital (GACH) for an accidental overdose (dangerous and excessive dose of a drug) of medication. (Cross reference F 658, F 760) Findings: During a concurrent observation and interview on 3/11/24 at 11:39 a.m. with Resident 1 in the dining room, Resident 1 finished her meal, stood without assistance and walked down the hallway. Resident 1's gait (a person's manner of walking) was slow and steady.…

    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 · D2023-10-26 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    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 report an alleged employee to resident physical abuse per their Policy and Procedure (P&P), Resident Allegations of Abuse by Staff for one of three sampled residents (Resident 1), when: 1. The facility did not notify the local law enforcement within 24 hours of the alleged abuse. 2. The facility did not perform a physical assessment of Resident 1 and did not notify a Physician, nor Psychiatrist of the alleged abuse incident. This failure placed Resident 1's safety at risk. Findings: During a review of Resident 1's Face Sheet (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), the face sheet indicated, Resident 1 was admitted to the facility on [DATE] with the following diagnoses, BIPOLAR DISORDER (disorder associated with episodes of mood swings), ANXIETY DISORDER (feelings of worry, anxiety or…

    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 · Ecited before2019-12-19 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure 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 interview and record review, the facility failed to ensure residents and their Responsible Party (RP) were informed of psychotropic (affecting mental activity, behaviors, and perceptions) medications dosages and frequency in accordance with the facility policy and procedure and professional standards of quality for three of seven sampled residents (Resident 146, Resident 148, and Resident 471) when: 1. Resident 146 and the Responsible Party (RP) were not informed of the dosage amount and frequency duration of Resident 146's three psychotropic medications: paliperidone (a medication used to treat schizophrenia) (a disorder characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, and decreased participation in daily activities), lithium carbonate (a medication to treat bipolar disorder) (a mental health condition that causes extreme mood swings), and mirtazapine (a medication to treat depression) (a mood disorder characterized by feelings of sadness…

    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 · F2018-12-14 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    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 the results of the Recertification, Abbreviated surveys and State agency (Department of Public Health Licensing and Certification -CDPHL&C) hotline phone number were located in a place readily accessible to the residents and the public for two of two sampled residents (Resident 16 and Resident 63). This failure denied residents and the public the right to be aware of Recertification, Abbreviated survey investigation results and access to the State agency hotline phone number. Findings: On 12/12/18 at 2:08 p.m., during an interview at the Resident Council meeting, Resident 16 and Resident 63 both stated they were not aware they could contact the State agency (Department of Public Health Licensing and Certification -CDPH L&C) for information, questions, concerns, and to submit complaints. Resident 16 and Resident 63 stated they did not know the hotline number for the State agency and the facility did not have the phone number posted for resident to access. On 12/12/18 at 2:10 p.m., during an interview 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2018-12-14 · tag F0655 — widespread
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a baseline resident-centered care plans were developed and implemented to address residents' preference and safety while smoking for 14 of 14 sampled residents (Resident 14, Resident 22, Resident 70, Resident 75, Resident 90, Resident 100, Resident 105, Resident 116, Resident 127, Resident 146, Resident 150, Resident 151, Resident 156, and Resident 162) when residents' smoking care plans were not developed within 48 hours of admission. This failure had the potential to negatively affect residents quality of care by not addressing the resident's smoking preference and safety while smoking. Findings: On 12/12/18 at 8:12 a.m., during a concurrent observation and interview with the Assistant Director of Nursing (ADON), Resident 70, Resident 105, Resident 15, Resident 162, Resident 75, Resident 116, Resident 146, and Resident 156 were smoking in the facility patio. The ADON stated smoking was allowed in designated areas and residents were supervised by Certified Nursing Assistants' (CNA). Review of facility residents…

    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 · Fcited before2018-12-14 · tag F0656 — failed to write and follow a full care plan — widespread
    Develop 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

    Based on interview and record review, the facility failed to ensure comprehensive resident-centered care plans (a plan that provides direction for individualized care of the resident) were developed and implemented to address residents' preference and safety while smoking for 14 of 14 sampled residents (Resident 14, Resident 22, Resident 70, Resident 75, Resident 90, Resident 100, Resident 105, Resident 116, Resident 127, Resident 146, Resident 150, Resident 151, Resident 156, and Resident 162) when 14 sampled residents did not have an individualized smoking care plan. This failure had the potential for residents smoking safety needs to go unmet. Findings: On 12/12/18 at 8:12 a.m., during a concurrent observation and interview with the Assistant Director of Nursing (ADON), Resident 70, Resident 105, Resident 15, Resident 162, Resident 75, Resident 116, Resident 146, and Resident 156 were smoking in the facility patio. The ADON stated smoking was allowed in designated areas and residents were supervised by Certified Nursing Assistants' (CNA). Review of facility's residents smoking…

    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 · F2018-12-14 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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, prepared, distributed and served in accordance with professional standards for food services when: 1. Dietary [NAME] (DC) 1 served ready to eat food using gloved hands that had touched objects and surfaces outside of the trayline. 2. DC 2 did not perform hand hygiene before placing gloves on hands during lunch trayline service. 3. There were two steel pans not properly air dried in the dishware storage area. 4. The ice machine lid hinge was found dirty. 5. There was no open date on a lemon juice bottle. 6. There were spoiled lemons in the walk in refrigerator. These failures placed the residents at risk for consumption of unsafe food handling and storage of receptacles used for food preparation. Findings: 1. On 12/11/18 at 11:30 a.m., during a lunch meal observation, DC 1 and DC 2 serviced the food counter in the large dining room. The food service area was equipped with a washing sink and a box of gloves available for the staff use. DC 1 was observed placing on a pair of gloves…

    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
Show the remaining 6 citations
  • Potential for harm · Ecited before2018-12-14 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure 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 2. On 12/12/18 at 3:15 p.m., during a concurrent medication administration observation and interview in station one, LVN 9 removed Amlodipine Besylate tablet (cardiac medication) from the prepared medications in a cup. LVN 9 stated Resident 11 refused to have blood pressure (BP) taken by a Certified Nursing Assistant. LVN 9 did not attempt to retake Resident 11's BP and did not administer the BP medication. Review of Resident 11's physician's order dated 12/18, indicated, Amlodipine Besylate tablet Give 10 mg [milligrams, unit of measurement] by mouth in the evening (1600) related to ESSENTIAL (PRIMARY) HYPERTENSION [high blood pressure] . Hold if pulse < [less than] 60 & [and] if BP <100/60 [physician order date] 10/31/18. On 12/13/18 at 5:45 p.m., during a review of Resident 11's medication administration record (MAR) with LVN 9. The MAR dated 11/18 indicated Resident 11 was not administered her cardiac medication 24 times due to refusals to have her BP and pulse taken and resident refused the medication two…

    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 · E2018-12-14 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    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 the medication error rate was five percent or lower for 12 of 52 sampled residents (Resident 24, Resident 39, Resident 43, Resident 53, Resident 59, Resident 60, Resident 103, Resident 107, Resident 121, Resident 125, Resident 146, and Resident 164) when: 1. Licensed Vocational Nurse (LVN) 9 did not follow the manufacturer's guideline for the administration of the inhalation medication for Resident 39. 2. LVN 9 administered expired Vitamin B6 on seven times to Resident 43. 3. LVN 5 administered medications past the physician prescribed medication administration time for Resident 24, Resident 59, and Resident 121. 4. LVN 6 administered medications past the physician prescribed medication administration time for Resident 53, Resident 60, Resident 103, Resident 107, Resident 125, Resident 146, and Resident 164. These failures resulted in a medication error rate of 7.33% and placed the residents' health and safety at risk when 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
  • Potential for harm · E2018-12-14 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    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 store and label drugs in accordance with currently accepted professional principles when: 1. A bottle of Vitamin B6 was stored with other over the counter drugs with an expiration date of 10/18. This failure placed the Resident 43 at risk of lowered efficacy with the potential use of expired drugs. 2. Licensed Vocational Nurse (LVN) 7 failed to appropriately secure medications when an unlocked medication cart was left unattended and out of sight of the licensed nurse. This failure had the potential for medications to be taken by residents, visitors, or staff and the potential for adverse effects if consumed. 3. Resident 32's medication, Lithium (a medication used to treat certain psychiatric illnesses) did not have an expiration date label on the bottle. This failure had the potential for Resident 32 to receive an expired medication with less efficacy to treat a psychiatric illness. Findings: 1. On 12/12/18 at 3:20 p.m., during a medication administration observation in Station One, LVN 9 prepared Resident…

    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 · E2018-12-14 · tag F0808 — failed to follow doctor-ordered diets — pattern
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    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 physician ordered diets were followed for two of three residents (Resident 95 and Resident 126) when salt packets were included on the residents' meal trays for residents ordered a no added salt (NAS) prescribed diet. This failure to follow physician ordered diets had the potential to further compromise the medical status of residents. Findings: On 12/11/18 at 11:30 a.m., during a concurrent observation and record review in Station Three dining room, there were four tables each with two to three residents seated, eating their lunch. In one of the four round tables, Resident 95 was eating. The tray card (contained the resident name, prescribed diet, and food & beverage preferences) indicated a regular diet, no added salt. Resident 95's meal tray was observed to have one packet of salt. Resident 126 was eating at the table and her tray card indicated a mechanical soft, no added salt diet. Resident 126's meal tray was observed to have one packet of opened salt. Resident 126 stated she put the salt on her…

    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 · Ecited before2018-12-14 · tag F0880 — failed to prevent and control infections — pattern
    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 maintain an infection prevention and control program affecting seven of seven sampled residents (Resident 10, Resident 46, Resident 49, Resident 73, Resident 112, Resident 115, and Resident 132) when the residents' hands were not washed nor sanitized before breakfast and lunch were served. This failure placed the residents' health and safety at risk for cross contamination and/or spread of infectious diseases. Findings: On 12/1/18 at 8:10 a.m., during a breakfast observation in the large dining room, Resident 10 entered the dining room using a walker. Resident 132 and Resident 112 propelled their wheelchairs toward one of the dining tables. The large dining room was observed with a sanitizer installed on the wall next to the dining room entrance. On 12/11/18 at 8:22 a.m., during an observation in the large dining room, Resident 10 and Resident 132 were served breakfast by Activity Assistant (AA) 2. Resident 10 and Resident 132 were not offered to sanitize their hands prior to eating breakfast. Resident 10 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2018-12-14 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    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 maintain equipment in operating condition when ice build-up was in the walk in freezer. This failure had the potential for the quality of food to be compromised for the residents. Findings: On 12/11/18 at 8:25 a.m., during an observation in the walk in freezer, the temperature in the freezer was negative 20 F (Fahrenheit). There was ice build-up along the entire inside edge of the freezer door. There was hardened ice build-up attached to the left upper corner of the shelf located on the right side of the freezer. There was hardened ice build-up on two aluminum trays containing frozen cookies. On 12/11/18 at 8:54 a.m., during an interview with the Maintenance Supervisor (MS) and the Kitchen Manager (KM), the MS stated the reason for the ice build-up in the freezer could be due to many reasons. The KM stated ice-build up could potentially lead to bad tasting food for the residents. The KM stated the quality of food could be compromised. The facility's undated policy and procedure titled, Sanitation 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.

    Environmental Deficiencies · Deficient, Provider has date of correction

“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
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

Paying with Medicaid

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.

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 05A024. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-15, 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.

What to do next