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Childrens Hc Org No Ca Saratoga Pediatric Subacute

13425 Sousa Lane, Saratoga, CA 95070 · For profit - Limited Liability company · 37 certified beds · (408) 378-8875 Medicare & Medicaid certified

Call the home — (408) 378-8875 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609) — most recent Mar 2025
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • 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.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ)Not rated
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
18241 Vanderbilt Dr
Pharmacy
1496 Pollard Rd · (408) 376-3554 · Call to confirm hours
Grocery
18850 Cox Ave · (408) 379-8300 · Call to confirm hours
Park
19085 Portos Dr · (408) 868-1249 · 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 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 held steady at 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 who lose too much weight2.4%4.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection1.6%1.2%2.0%better
Long-stay residents with depressive symptoms1.9%7.3%6.5%better
Long-stay residents who were physically restrained0.8%0.4%0.1%worse than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%1.6%3.3%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication34.1%13.7%18.9%worse
Long-stay residents given the seasonal flu vaccine96.7%98.2%95.3%typical
Long-stay residents with pressure ulcers0.0%4.3%4.7%check this — see note marked star below the table
Long-stay residents with worsening bladder/bowel control0.0%10.2%21.2%check this — see note marked star below the table
Long-stay residents who got an antipsychotic medication — see the note below the table0.0%12.0%17.1%check this — see note marked star below the table

* 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

CMS has not published payroll-based (PBJ) staffing hours for this facility yet — this can happen for newer, hospital-based, or recently-certified homes. It can also mean the home simply did not file, which CMS does not distinguish in this data, so treat the gap as unexplained rather than benign. Staffing is one of the three parts of the CMS star rating; where it’s missing, weigh the independent health-inspection score most, and ask the facility directly about its nurse-to-resident ratios and weekend RN coverage.

Inspection trend

4
deficiencies at the latest standard inspection (2026-02-10)
6
at the previous standard inspection (2024-07-23)

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.

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.

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 · D2026-06-26 · 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 interview, and record review, the facility failed to maintain and meet current standards of nursing practice when, the medication was not administered according to the physician's order for one of two residents (Resident 1). This failure could potentially result in complications of the residents' medical conditions.Findings: Review of Resident 1's clinical record indicated she was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including spastic quadriplegic cerebral palsy ( a permanent physical disability affecting both arms, legs, facial muscle, trunk and making movements is difficult).Review of Resident 1's Physician Order Summary Report dated 2/13/26 and 3/14/26 indicated Atropine Sulfate Ophthalmic Solution 1% (a medication used in the eye, medication also with off label to treat severe drooling) administer three drops sublingually (under the tongue) three times a day for excess saliva.During a concurrent interview and record review with the Administrator (ADM) on…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-10 · tag F0656 — failed to write and follow a full care plan — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement specific, individualized and resident-centered care plans for the side or bed rails (adjustable rigid bars attached to the side of a bed) of twelve, (Residents 16, 19, 4, 27, 5, 1, 29, 6, 32, 14, 24 and 12), out of thirty-three residents in the facility, when these twelve residents who used side rails did not have specific, individualized and resident-centered care plans for their side rails. These failures had the potential for these residents to be at risk, for not being properly monitored and provided with the appropriate interventions with regards to their use of side rails, which could compromise their safety and quality care.Findings: 1. During the observation of Resident 16, on 2/5/26 at 12:55 p.m., Resident 16 was in his wheelchair inside his room, comfortable and not talking. Resident 16 had bilateral (both sides) padded upper side rails that were up. Review of Resident 16's admission record (document…

    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 · E2026-02-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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

    Based on observation, interview, and record review, the facility failed to ensure residents' environment remained free of accident hazards to prevent avoidable accidents, in order to provide safe environment for residents when there were missing logs in their laundry dryer lint tray cleaning monitoring sheet for February 2026. These failures had the potential for causing fire accident that might result in injury and harm to the thirty-three residents residing in the facility.Findings: During the laundry room observation on 2/10/26 at 11:05 a.m., there were missing logs in the dyer lint tray cleaning monitoring sheet for February 2026, that included the removal of the dryer lint (a collection of fine fabric and yarn pieces that accumulate in a dryer's filter while clothes were being dried). There were logs missing for the nocturnal shift (NOC, the overnight, third shift of the facility), which would start from 10:00 p.m. at night until 5:00 a.m. in the morning. The NOC shift laundry staffs missed to log in the dryer lint tray cleaning monitoring sheet for the following dates: 2/2/26,…

    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
  • Potential for harm · Dcited before2026-02-10 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility had a medication error rate of 14.29% when 4 medication errors out of 28 opportunities were observed during medication pass for two of ten residents (Residents 8 and Resident 16). These failures had the potential to compromise the health and safety of the residents.Findings: During a medication pass on 2/6/26 at 2:16 p.m., licensed vocational nurse (LVN) A was observed preparing two medications for seizures for Resident 8. Included in the medications were a tablet of topiramate 25 milligrams (mg, unit of measurement) dissolved in 3 milliliter (ml, unit of measurement) of water and 3 ml of levetiracetam. On 2/6/26 2:20 p.m., LVN A was observed that he combined and administered topiramate dissolved in 3 ml of water and 3 ml of levetiracetam 100mg/ml all at once via G-Tube (a tube surgically inserted through the abdomen into the stomach to administer nutrition and medications.) During an interview with LVN A on 2/6/26 at 2:25 p.m., LVN A confirmed that he combined the medications topiramate and levetiracetam in a purple…

    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 · Dcited before2026-02-10 · tag F0761 — failed to label and store drugs safely — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an expired medication was removed from one of four medication carts inspected for one of thirteen sampled residents (Resident 3); and, three expired control solutions (liquid solution used to verify that a blood sugar machine and test strips are working accurately together) were not removed from an active use supply area of a medication room.These failures had the potential for the residents to receive expired medication and/or be inaccurately assessed for blood sugar.Findings:During an inspection of the medication room with the infection control preventionist (IP) on [DATE] at 10:41 a.m., the IP confirmed one Assure dose control solution had expired on 2025-03-09 and two [NAME] control solution had expired on 2025-10-10 and 2025-08-10 and stated that the solutions should be discarded.During an inspection of the medication cart (Med Cart B) with the IP on [DATE] at 10:55 a.m., Resident 3's medication hydralazine (medication to…

    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 · D2025-03-17 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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 report an allegation of abuse involving one of two sampled residents (Resident 1) to the State Survey Agency. This failure had the potential to delay investigations and compromise Resident 1's safety. Findings: Review of Resident 1's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including congenital central alveolar hypoventilation syndrome ( a rare, life-threatening genetic disorder that affects normal breathing), short bowel syndrome with colon in continuity (a rare malabsorption disorder that occurs when the small intestine is damaged or shortened preventing it from absorbing enough nutrients from food), chronic respiratory failure with hypercapnia (a condition where the body cannot adequately remove carbon dioxide from the blood), dependence on respirator status (unable to breathe independently after being on a ventilator). During an interview on 12/19/24 at 10:09 a.m., with the Respiratory…

    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 · F2024-07-23 · tag F0700 — widespread
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 their Bed/Side Rails policy for 20 of 22 residents (1, 2, 3, 4, 5, 6, 9, 11, 14, 16, 18, 23, 24, 25, 27, 181, 182, 184, 330, and 331) when they did not attempt alternative measures prior to applying bed side rails. This failure had the potential to place the residents at risk of entrapment and serious injury. Findings: During an observation in Resident 11's room on 7/15/24, at 10:19 a.m., Resident 11 was in bed with side rails up. Review of Resident 11's physician order, dated 2/7/23, indicated she had an order for Upper Side Rails. Review of Resident 11's Postural Support/Developmental Safety Device Rationale and Consent, dated 12/19/23, indicated alternative measures were not attempted prior to the use of side rails. During an observation in Resident 1's room on 7/15/24, at 10:20 a.m., Resident 1 was in bed with left side rail up. Review of Resident 1's physician order, dated 7/12/23, indicated she had an order for Left Side Rail. Review of Resident 1's Postural Support/Developmental Safety Device…

    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
  • Potential for harm · E2024-07-23 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen when: 1. Food was kept beyond their open and expiration dates, 2. Temperature logs for two refrigeration units had missing entries, 3. Five opened spice containers were without expiration dates, 4. Three cutting boards had deep cut marks on their surface, 5. Five red onions and four yellow onions were moldy, six potatoes were soft and wrinkled, and 6. A fan had dark particles on its fan blades and grills. These failures had the potential to cause food-borne illness for residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview with the dietary supervisor (DS) on 7/15/24 at 8:40 a.m., the DS confirmed the following food items located in active use areas of the kitchen were expired: potato salad, left over beans in an unsealed bag dated 7/8/24, an open bag of broccoli dated 6/24/24. The DS stated left over food are kept 3-5 days the left over beans you have been in a sealed bag. Review of facility's undated policy and…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-23 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control practices when the filters of oxygen concentrators were dusty for five of 13 residents (3, 23, 25, 183, and 184). This failure had the potential to spread infection in the facility. Findings: Review of Resident 3's admission Record indicated she was admitted to the facility on [DATE] with a respiratory failure (a condition that makes it difficult to breathe; respiratory failure develops when the lungs cannot get enough oxygen into the blood) diagnosis. Review of Resident 3's physician order, dated 5/10/24, indicated she had an order for oxygen as needed to keep her oxygen saturation (O2 Sat, the amount of oxygen that's circulating in the blood) above 92%. During an observation with respiratory therapist D (RT D) on 7/15/24, at 10:41 a.m., the filter of Resident 3's oxygen concentrator had a layer of dust on it. RT D confirmed the filter of Resident 3's oxygen concentrator was dusty. Review of Resident 23'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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-23 · 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

    Based on interview and record review, the facility failed to implement their abuse policy by failing to obtain background checks for one of three certified nursing assistants (CNA C), when CNA C was hired without a background check. This failure had the potential to put the residents at risk for abuse. Findings: Review of CNA C's personal file indicated she was hired to the facility on 2/8/24, but there was no background screening found for her. During an interview with the director of staff development (DSD) on 7/19/24, at 4:05 p.m., he stated he would check with human resources for CNA C's background check document. During an interview with the DSD on 7/23/24, at 12:36 p.m., he stated he checked with human resources and confirmed that CNA C did not have a background screening done when she was hired on 2/8/24. Review of the facility's undated policy, Abuse, indicated, . C. Screening: a. The facility will not knowingly employ any individual convicted of resident abuse, misappropriation of resident property, or reported abuse as noted by licensure boards of registries. Upon hire,…

    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
Show the remaining 8 citations
  • Potential for harm · Dcited before2024-07-23 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the nursing staff administered a medication accurately according to the manufacturer's specifications for one of 12 sampled residents (Resident 331), when Resident 331's Lansoprazole (drug used to reduce stomach acid) Oral Disintegrating Tablet (ODT, fast-melting tablet that dissolves quickly in saliva/water) 30 milligrams (mg, unit of mass measurement) was crushed before administration, contrary to the manufacturer's guidelines. This failure had the potential to reduce medication efficacy for Resident 331. Findings: During an observation of a medication administration on 7/15/24 at 8:28 a.m., Licensed Vocational Nurse A (LVN A) crushed a tablet of lansoprazole ODT 30 mg then mixed it with water prior to administering the mixture to Resident 331. During an interview with LVN A on 7/15/24 at 8:38 a.m., she stated she crushed all of Resident 331's medications according to Resident 331's physician's orders. During a concurrent interview and record review on 7/15/24 at 2:32 p.m. with LVN A, review of 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 · Dcited before2024-07-23 · tag F0761 — failed to label and store drugs safely — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a multi-dose medication was labeled with an open date after opening, and not stored beyond its discarding date. This failure had the potential for residents to receive expired, contaminated, or deteriorated medication. Finding: During an observation and record review with Registered Nurse B (RN B) on [DATE] at 10:12 a.m., an open 10 milliliter (mL) multi-dose vial of lorazepam (a controlled medication to treat seizures and agitation) 2 milligrams/mL was identified in the medication refrigerator without an open date on the vial. RN B reviewed the Controlled Drug Record and stated the lorazepam vial was opened on [DATE] (4 months ago). He acknowledged the vial should have been labeled with an open date. During a follow-up interview on [DATE] at 2:08 p.m., RN B stated he checked with the pharmacy and was told the lorazepam vial should be discarded 28 days after it was punctured. During a telephone interview with the Consultant…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2020-01-23 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were followed when: 1. Housekeeper (HK E) did not change gloves and did not perform hand hygiene; 2. Resident 4's oxygen nasal cannula tubing (a device used to deliver supplemental oxygen or airflow) was touching the bedside table; 3. Resident 4's oxygen connector was exposed and touching the side rail; 4. Medication cart garbage next to the Resident 4's bedside table was over flowing; 5. Certified nursing assistant M (CNA M) did not change gloves and did not perform hand hygiene; 6. Ambu bags were not stored inside the equipment containers. These failures had the potential to spread infection in the facility. 1. During an observation on 1/21/2020 at 1:12 p.m. HK E exited room [ROOM NUMBER] with gloves then proceeded to room [ROOM NUMBER] without changing or removing gloves. HK E exited room [ROOM NUMBER] with the same gloves, proceeded to collect the medcart garbage and entered room [ROOM NUMBER]…

    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 · Dcited before2020-01-23 · 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

    Based on interview and record review, the facility failed to implement their abuse policy when a skin discoloration of unknown origin was not investigated to rule out abuse. This failure placed the resident at risk for abuse. Findings: During an observation 1/21/2020 at 9:17 a.m., Resident 18's right wrist had a purplish-yellowish discoloration approximately a size of a quarter coin. During a concurrent observation and interview on 1/21/2020 at 4:12 p.m. with registered nurse A (RN A), RN A confirmed the above observation and stated the skin discoloration was fading. RN A confirmed there was no documentation regarding the skin discoloration. RN A further stated, she was not aware of what happen to the skin. During a review of Resident 18's weekly summary dated 1/19/2020, the weekly summary did not indicate a skin discoloration on the right wrist. During a review of Resident 18's progress notes dated 1/20/2020, the progress notes indicated no new skin issues noted. During a concurrent interview and record review on 1/22/2020 at 2:09 p.m. with the director of nursing (DON), the DON…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-01-23 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow facility policy related to accountability and documentation of controlled substances (drugs with high potential for abuse and addiction) for four out of six sampled residents when: 1. For Resident 21, quantity of a controlled substance received from the pharmacy does not match what was documented. 2. For Resident 29, a controlled substance was delivered by a licensed nurse to a general acute hospital without obtaining permission to leave and missing documentation related to physician's order. 3. For Resident 1, a controlled substance was not properly documented. 4. For Resident 30, 4.6ml (milliliters, a unit of measurement) of a controlled substance was not accounted for and not reported immediately to responsible supervisor. These failures had a potential for diversion of highly controlled substances. Findings: 1. For Resident 21, quantity of a controlled substance received from the pharmacy does not match what was documented.…

    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 · Dcited before2020-01-23 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility had 8% medication error rate when two medication errors out of 25 opportunities were observed during medication pass. This failure resulted in Resident 30 not getting his medications as ordered by the physician. Findings: 1. During medication pass observation on 1/21/2020 at 4:56 p.m. with Registered Nurse B (RN B), RN B did not give the half remaining portion of crushed glycopyrrolate (medication used to reduce drooling in children ages 3 to 16 who have certain medical conditions, such as cerebral palsy) in the medication cup. During an interview on 1/21/2020 at 6:00 p.m. with RN B, he acknowledged the above observation. RN B further stated that he forgot to give the half remaining portion of the medication to complete the dose as ordered by the physician. During a review of the physician order, dated 12/5/2019, indicated Resident 30 was to receive glycopyrrolate half tablet of 1 milligram (mg, a unit of measurement) 0.5 mg. via gastrostomy tube (GT, a tube inserted through the abdomen into the stomach) every eight…

    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 · Dcited before2020-01-23 · tag F0761 — failed to label and store drugs safely — isolated
    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

    2. During a breathing treatment observation on 1/21/2020 at 5:41 p.m. with respiratory therapist C (RT C), RT C had a medication room key to get Resident 4's respiratory medications inside the medication room without the facility licensed nurse present. During an interview on 1/21/2020 at 6:04 p.m. with RT C, RT C acknowledged the above observation. RT C further stated she had her own key to enter the medication room without the facility licensed staff present. During a breathing treatment observation on 1/21/2020 at 4:40 p.m. with RT F, RT F had a medication room key to get Resident 12' s respiratory medications inside the medication room without the facility licensed nurse present. During an interview on 1/21/2020 at 5:31 p.m. with RT F, RT F confirmed the above observation. RT F stated he had his own key to go inside the medication room without facility licensed staff present. During an interview on 1/23/2020 at 12:43 p.m. with the administrator (ADM), he stated only licensed nurses should have the key to the medication room. He further stated respiratory therapists should 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-01-23 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    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 aerosol disinfectant was stored properly when the chemical disinfectant was found at the bed side of Resident 4. This failure had the potential for Resident 4 to access the hazardous chemical and jeopardize his health and safety. Findings: During breathing treatment observation on 1/21/2020 at 5:41 p.m. with respiratory therapist C (RT, a specialized healthcare practitioner trained in pulmonary medicine in order to work therapeutically with people suffering from pulmonary disease), a one 19 oz. disinfectant aerosol bottle was found at the bedside table next to the breathing treatment machine and suction machine for Resident 4. During a concurrent observation and interview with RT C on 1/21/2020 at 5:51 p.m., RT C acknowledged the above observation. She further stated Resident 4 could easily grab the aerosol bottle and it should not be kept at the bedside for Resident 4's safety. During a concurrent observation and interview with registered nurse B (RN B) on 1/21/2020 at 5:54 p.m., he acknowledged 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.

    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 / managerTypeRoleShareSince
INNOVATIONS HEALTH SYSTEMS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 10/17/2016
MCGUIRE, KENNETHIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER50%since 09/01/2019
NICCUM, DANIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST50%since 10/17/2016
BARRETT, ROBERTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2019
DICARLO, JOSEPHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2017
STUKOV, SAMUELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/03/2023

CMS files one row per role, so the 10 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

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

What families pay in CA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555204. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-10, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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