Valley Of The Moon Post Acute

Location & what’s nearby

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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

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.

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

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

64.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 85 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 81.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 27 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.17 therapist hours per resident per day in 2026Q1 — more than 16% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 27 beds and averages 26.0 residents a day — about 96% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.05 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.55 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.48 hrs/resident/day on weekends vs 5.28 on weekdays — 15% thinner on weekends. RN hours go from 0.74 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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

29 citations, most serious first. The 13 most serious are shown; the remaining 16 are one tap away and print in full.

• Actual harm · G2026-04-15 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect one (Resident 1) of five sampled resident's right to be free from physical abuse when Resident 1 was struck by Resident 2 during an altercation that occurred on 3/06/26.This failure resulted in Resident 1's suffering bruising and skin tears to the face and arms. Resident 1 also experienced lasting anxiety following the facility failure.A review of Resident 's admission Record (facility demographic) indicated he was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (oxygen and nutrients to part of the brain is blocked causing brain tissue death) with hemiplegia and hemiparesis (hemiparesis indicates weakness on one side of the body; hemiplegia indicates partial or total paralysis) diabetes (when your blood sugar is too high), and heart failure (a chronic, progressive condition where the heart cannot pump enough blood to meet the body's needs, causing fatigue, shortness of breath, and fluid…

  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
• Actual harm · G2019-10-16 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate nutrition and hydration services for 2 out of 8 sampled residents (Resident 1 and 10). For Resident 1, the facility failed to identify, implement, and monitor interventions, consistent with the resident's assessed needs and facility policy, which resulted in a severe unplanned weight loss of 8.36% within a three month timeframe from 7/10/19 to 10/3/19. For Resident 10, the facility failed to provide fluid on the lunch meal tray, which had the potential to result in dehydration. Findings: 1. During a review of the clinical record for Resident 1, the admission Record, dated 10/16/19, at 11:53 a.m., indicated Resident 1 was admitted to the facility on [DATE]. The record indicated Resident 1 was admitted for the primary diagnosis of Alzheimer's Disease (A progressive disease that destroys memory and other important mental functions). The record further indicated Resident 1 was diagnosed with anxiety, major depressive disorder…

  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 · G2019-10-16 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  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 staff followed its policies to provide pain management for two of twelve sampled residents (Resident 76 and Resident 77). This failure resulted in 1) Resident 76 suffering from intolerable pain, up to a level 10, on a pain scale from 0 to 10 (0 being no pain, 10 being the worst pain experienced in one's lifetime) and crying for two weeks from back pain, and 2) Resident 77 suffering from severe pain, up to a level 9, on a pain scale from 0 to 10 for four days from a left femur (Thigh bone) fracture, which made her unable to participate in physical therapy, and become depressed. Findings: 1) Resident 76 Resident 76 was admitted to the facility on [DATE] with medical diagnoses including Low Back Pain, Neuralgia (Intense, typically intermittent pain along the course of a nerve) and Pain in Thoracic Spine (Pain caused by joint dysfunction where the ribs attach to the spine), according to the facility Face Sheet (Facility demographic).…

  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 · Ecited before2024-10-11 · tag F0550 — failed to protect resident dignity and rights — pattern
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident right to know about, and had access to, the contact information for the Ombudsman (State Patient/Resident advocacy services) and California Department of Public Health (CDPH) and Federal and State Survey results. This failure had the potential for not allowing Residents or their family members to exercise their right to know contact advocates about their concerns regarding the care they received in the facility and how to view the results of the facility surveys and the plans of correction (A document from the facility that would state how to correct any deficiencies or findings, and to keep them from happening again.) prepared by the facility in response to a complaint investigation or recertification survey. Findings: (Cross Reference F575, F577) During an observation on 10/7/24, at 2:30 p.m., the bulletin boards across from the nursing station to the right of room [ROOM NUMBER] were observed to be blocked by one of 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 Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-10-11 · tag F0577 — pattern
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents knew about, and had access to, the contact information for the Ombudsman (State Patient/Resident advocate services) and California Department of Public Health (CDPH) and Federal and State Survey results. This had the potential for not allowing Residents or their family members to exercise their right to know contact advocates about their concerns regarding the care they received in the facility and how to view the results of the facility surveys and the plans of correction. Findings: (Cross Reference F550, F575) During an observation on 10/7/24, at 2:30 p.m., the bulletin boards across from the nursing station to the right of room [ROOM NUMBER] were observed to be blocked by one of two medicine carts. During an observation on 10/7/24, at 4:15 p.m., the activity / dining room, and the staff break room was observed to not have a poster that indicated how to contact the Ombudsman, CDPH, or where to find the facility survey…

  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 · E2024-10-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
  Provide safe and appropriate respiratory care for a resident when needed.
  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 clinical record review, the facility failed to maintain a portable oxygen tank inventory and properly anticipate emergent respiratory care equipment needs for six Sampled Residents (Resident 4, Resident 2, Resident 1, Resident 13, Resident 80, Resident 6), and 2 Unsampled Resident (Resident 5, Resident 9) who received oxygen therapy. The facility's inability to ensure Resident's daily and emergent oxygen needs had the potential for Respiratory Distress (shortness of breath, difficulty breathing, and possible respiratory failure), Hypoxemia (oxygen deprivation) and potential for death, during a facility evacuation that required transport of residents to county shelters or private homes. Findings: During an observation and interview, on 10/7/24 at 2:45 p.m., Sampled Resident 4 was observed in her bed. The head of her bed was at 45 degrees. Oxygen was being delivered via nasal cannula (through the nose) connected to a wall mounted medical gas delivery system at 2 Liters per…

  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 · E2024-10-11 · 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

  Based on interview and record review, the facility: 1) Failed to ensure Registered Nurses (RNs) had accurate, verified competencies (verification of essential job functions; skills/ability required to perform safe nursing care) in their employee files when 2 of 2 sampled Registered Nurses (RN B and RN C) did not have documented, complete PICC line (peripherally inserted central catheter) competencies per facility policy, and 2) Failed to ensure Licensed Vocational Nurse L (LVN L) had accurate competencies in his employee file when LVN L's employee file indicated he had PICC line competencies, but LVN's are not legally nor professionally qualified to care for PICC lines. These deficiencies caused potential for unsafe nursing practice and potentially placed PICC residents at risk of harm. (A PICC line is an intravenous catheter [also called a central line] that is inserted into a vein in the arm, which is advanced toward the heart until the tip rests in the vein near the heart. A PICC is used to administer medication directly into the large vein near the heart). Findings: Review of…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-10-11 · 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 did not ensure the safety of one sampled resident (Sampled Resident 1), when medication that was ordered to be administered on an empty stomach was administered at the same time as two medication that were ordered to be administered with food. This medication administration was the result of not following the physician's order and had the potential to result in medication not being absorbed properly and the risk of Sampled Resident 1 to experience side effects that included gastric upset, nausea and gastric reflux. Finding: During an observation on 10/8/24, at 8:51 a.m., Licensed Vocational Nurse K administered Gabapentin (Medication used to treat pain), Omeprazole DR (Medication used to decrease the amount of acid produced by the stomach.) and Metformin (Medication used to treat diabetes) to Sampled Resident 1. During an interview and record review on 10/8/24 at 8:55 a.m., Licensed Vocational Nurse K stated breakfast was served between 7:30 a.m.…

  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 · F2023-07-28 · tag F0727 — failed to provide required RN coverage — widespread
  Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, and record review, the facility failed to provide the services of a Director of Nursing (DON) on a full time basis for the last thee months. This failure prevented the oversight of a professional Registered Nurse (RN) in the management and direction of all aspects of the nursing services department that could adversely impact the care and treatment of residents residing in the facility. Findings: During an interview on 7/24/23, at 11:52 AM, the Administrator stated the facility did not have a Director of Nursing. During an interview on 7/27/23, at 3:15, the Director of Staff Development (DSD) stated the facility did not have a full time DON since early 4/2023. During a follow-up interview on 7/28/23, at 2:29 PM, the Administrator stated he had been the Administrator since 1/2023 and the facility had been without a DON since 4/2023. The Administrator stated the facility already had a corrective action plan and prospects for the position of DON but wanted to ensure they hired a candidate who will best fit the position. A review of the facility document titled,…

  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 · Ecited before2023-07-28 · 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

  Based on observation, interview and record review, the facility did not create a care plan for one of two residents (Resident 11) who was on supplemental oxygen (O2) for 7 months. This failure could result to oxygen toxicity or oxygen poisoning (lung damage that happens from breathing in too much extra [supplemental] oxygen), which can cause coughing, trouble breathing, and in severe cases it could potentially cause death. Findings: During the initial tour of the facility on 07/25/23 at 11:36 AM, Resident 11 was observed seated in her wheelchair at the bedside. Resident 11 was on O2 via a nasal cannula (a thin tube which delivers oxygen into the nose) and was receiving the O2 at two Liters (unit of volume) Per Minute (2 LPM). During a follow-up visit on 07/27/23 at 11:19 AM, Resident 11 was on O2 via nasal cannula at 2 LPM. During a review of records on 07/27/23 at 11:54 AM, Resident 11's face sheet (one-page summary of important information about a patient including patient identification, past medical history, medications, allergies, insurance status, or other pertinent…

  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 · Ecited before2023-07-28 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and a review of records, it was determined that the facility failed to meet the pharmaceutical needs of its residents by not having proper procedures in place to ensure the accurate administration of all drugs. Specifically, during the administration of an insulin injection to Resident 25, it was observed that the injection site was not rotated, and the same site was used multiple times by several different nurses. This could potentially lead to an adverse reaction such as lipodystrophy (a disorder that affects how the body accumulates and stores fat). Findings: A review of the Lispro insulin manufacture's insert indicated that Lispro was a type of medicine that helps people with diabetes keep their blood sugar at a healthy level. Lispro subcutaneous administration (given as a shot under the skin) should be given in different places on the body like the stomach, thigh, upper arm, or buttocks. It's important to rotate (change where the shot is given each time) the injection site so that the skin stays healthy. This is because long-term use of Lispro insulin can…

  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 · E2023-07-28 · tag F0756 — failed to review each resident's drug regimen — pattern
  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and record reviews, it was discovered that the facility pharmacist failed to report irregularities, and the facility itself did not take appropriate action in response to these irregularities. The facility pharmacist failed to identify the lack of insulin site rotation for Resident 25, which resulted in the resident at risk for lipodystrophy due to repeated injection at the same site. Lipodystrophy is a disorder that affects how the body accumulates and stores fat. Findings: During a review on 7/24/23 of Resident 25's Medication Administration Record (MAR) and following an observation and interview with LVN A, a concerning pattern was identified. Multiple different nurses had failed to rotate the insulin administration sites properly, which raised concerns about the potential development of complications. The number of instances of non-rotated injection sites were as follows: 6/7/2023: - Bedtime dose administered insulin in the lower upper quadrant of the abdomen. - Next dose administered insulin in the lower upper quadrant of the abdomen. 6/9/2023: - Afternoon…

  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 · E2023-07-28 · 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

  Based on observations, interviews, and a review of records, it was found that the facility failed to maintain a medication error rate of less than 5%. During the medication pass, three medication errors were observed out of twenty-nine opportunities, resulting in an error rate of 10%. Findings: 1. A review of the Lispro insulin manufacturer's insert indicated that Lispro is a type of medicine that helps people with diabetes keep their blood sugar at a healthy level. Lispro subcutaneous administration (given as a shot under the skin) should be given in different places on the body like the stomach, thigh, upper arm, or buttocks. It's important to rotate (change where the shot is given each time) the injection site so that the skin stays healthy. This is because long-term use of Lispro insulin can cause lipodystrophy at the site of repeated insulin injections. Lipodystrophy is a disorder that affects how the body accumulates and stores fat. A review of Resident 25's electronic record on 7/24/23, it was noted that the physician had ordered a sliding scale (a way to adjust the amount of…

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

  Pharmacy Service 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.

Fines & penalties

$13,065 in federal fines across 1 penalty.

• $13,065 — penalty dated 2026-04-15

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

CMS files one row per role, so the 12 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

What families pay in CA