Cycle 1
Health 2025-08-08 · Fire 2025-08-08
3 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
San Pablo, CA
Creekside Healthcare Center
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1900 Church Lane, San Pablo, CA
(510) 235-5514
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
71
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Mariner Health Care
Operator or chain grouping
Approved since
1970-02-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
18 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.58
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.57
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
5.18
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.62
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.76
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
1.40
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.44
CMS adjusted RN staffing hours
Adjusted total hours
4.73
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,695
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.23
Composite VBP score used to determine payment impact.
Payment multiplier
1.0019
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.38
Baseline 16.64% · Performance 18.48% · Measure score 6.38 · Achievement 6.38 · Improvement 0
Healthcare-associated infections
2.68
Baseline 6.09% · Performance 7.03% · Measure score 2.68 · Achievement 2.68 · Improvement 0
Total nurse turnover
6.29
Baseline 24.19% · Performance 37.97% · Measure score 6.29 · Achievement 6.29 · Improvement 0
Adjusted total nurse staffing
3.95
Baseline 4.39 hours · Performance 4.20 hours · Measure score 3.95 · Achievement 3.95 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.37% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 71 · Observed rate 14.08% · Lower 95% interval 7.67% |
| Discharge to community | 48.86% |
50.57%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 69 · Observed rate 36.23% · Lower 95% interval 37.06% |
| Medicare spending per beneficiary | 1.3 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 60.61% |
95.27%
34.7 pts worse
|
Numerator 20 · Denominator 33 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 33 |
| Discharge self-care score | 60.87% |
53.69%
7.2 pts better
|
Numerator 14 · Denominator 23 |
| Discharge mobility score | 73.91% |
50.94%
23 pts better
|
Numerator 17 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 6.06% |
2.29%
3.8 pts worse
|
Numerator 2 · Denominator 33 · Adjusted rate 5.83% |
| Healthcare-associated infections requiring hospitalization | 7.03% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 9.09% · Lower 95% interval 3.52% |
| Staff COVID-19 vaccination coverage | 17.31% |
8.2%
9.1 pts better
|
Numerator 18 · Denominator 104 |
| Staff flu vaccination coverage | 52.25% |
42%
10.2 pts better
|
Numerator 58 · Denominator 111 |
| Discharge function score | 78.26% |
56.45%
21.8 pts better
|
Numerator 18 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 81.48% |
96.28%
14.8 pts worse
|
Numerator 22 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 38.1% |
25.2%
12.9 pts better
|
Numerator 8 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.3
0.6 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.7 · Expected 3.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.6
About the same
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.8 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
1.6%
1.2 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.9% |
6.8%
0.9 pts better
|
11.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 4.4% · Q3 6.4% · Q4 7.5% · 4Q avg 5.9% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
4.1%
1.7 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 7.4% · Q3 5.2% · Q4 2.0% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.2% |
13.7%
8.5 pts better
|
19.6%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.4% · Q3 5.0% · Q4 5.9% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.4% |
14.2%
0.8 pts better
|
16.7%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 17.6% · Q3 10.3% · Q4 11.4% · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.8% |
0.4%
0.4 pts worse
|
0.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 1.9% · 4Q avg 0.8% |
| Percentage of long-stay residents whose ability to walk independently worsened | 29.4% |
11.0%
18.4 pts worse
|
16.3%
13.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.2% |
10.7%
9.5 pts worse
|
14.9%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 22.7% · Q3 20.9% · Q4 22.9% · 4Q avg 20.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.0%
0.7 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
1.2%
0.1 pts worse
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.3% · Q4 2.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.2% |
10.9%
1.3 pts worse
|
19.8%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 10.6% · Q3 12.3% · Q4 4.9% · 4Q avg 12.2% |
| Percentage of long-stay residents with pressure ulcers | 13.9% |
4.7%
9.2 pts worse
|
5.1%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 11.5% · Q3 14.0% · Q4 20.1% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.8% |
11.2%
9.6 pts worse
|
12.0%
8.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 21.7% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.8% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.2%
6.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.1% |
23.2%
8.9 pts worse
|
23.9%
8.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.1% · Observed 36.7% · Expected 27.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-24 · Fire 2024-05-24
10 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-05-05 · Fire 2022-05-05
7 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-08-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-08-14
F · Potential for more than minimal harm
2025-07-21
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2025-07-29
E · Potential for more than minimal harm
2024-05-24
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-06-17
E · Potential for more than minimal harm
2024-05-24
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-06-17
E · Potential for more than minimal harm
2024-05-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-17
E · Potential for more than minimal harm
2024-05-24
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-24
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-24
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-17
D · Potential for more than minimal harm
2022-05-05
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2022-05-23
D · Potential for more than minimal harm
2022-05-05
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-05-23
D · Potential for more than minimal harm
2022-05-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-05-23
D · Potential for more than minimal harm
2022-05-05
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-05-23
D · Potential for more than minimal harm
2022-05-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-05-23
D · Potential for more than minimal harm
2022-05-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-05-23
D · Potential for more than minimal harm
2022-05-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-23
D · Potential for more than minimal harm
2022-05-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-05-23
D · Potential for more than minimal harm
2022-05-05
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-05-23
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-08
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-09-07
E · Potential for more than minimal harm
2025-08-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-07
D · Potential for more than minimal harm
2025-08-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-09-07
F · Potential for more than minimal harm
2024-05-24
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-06-19
E · Potential for more than minimal harm
2024-05-24
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-06-19
E · Potential for more than minimal harm
2024-05-24
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-06-19
E · Potential for more than minimal harm
2024-05-24
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-24
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-24
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-24
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-04-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-05-02
E · Potential for more than minimal harm
2022-05-05
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-06-04
E · Potential for more than minimal harm
2022-05-05
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-06-04
E · Potential for more than minimal harm
2022-05-05
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-06-04
E · Potential for more than minimal harm
2022-05-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-06-04
D · Potential for more than minimal harm
2022-05-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-06-04
D · Potential for more than minimal harm
2022-05-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-06-04
D · Potential for more than minimal harm
2022-05-05
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-06-04
Penalties and ownership
What sits behind the stars
Ownership
Gc Holding Company 2 LLC
5% Or Greater Direct Ownership Interest · Organization
Creekside Holding Company Gp LLC
General Partnership Interest · Organization
Dhugga, Gurpreet
Contracted Managing Employee · Individual
Gc Holding Company 2 LLC
Limited Partnership Interest · Organization
Grancare LLC
5% Or Greater Indirect Ownership Interest · Organization
Grunstein, Emily
5% Or Greater Indirect Ownership Interest · Individual
Huang, Phil
W-2 Managing Employee · Individual
Macaraeg, Lena
W-2 Managing Employee · Individual
Mariner Health Care, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Mhc Holding Company
5% Or Greater Indirect Ownership Interest · Organization
Mhc West Holding Company
5% Or Greater Indirect Ownership Interest · Organization
National Senior Care, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Rotich, Janet
Corporate Officer · Individual
Rotich, Janet
W-2 Managing Employee · Individual
Sarcauga, Dennis
Operational/Managerial Control · Individual
Sarcauga, Dennis
Corporate Officer · Individual
Taetz, Linda
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Vale Healthcare Center
San Pablo, CA
4-star overall rating with 3-star inspections with 16 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
San Pablo Healthcare & Wellness Center
San Pablo, CA
2-star overall rating with 2-star inspections with abuse icon flag with $10,036 in total fines with 11 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Richmond Post Acute Care
Richmond, CA
5-star overall rating with 4-star inspections with $36,343 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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