Federal inspection record · CMS data as of October 1, 2026
Golden San Andreas Care Center
900 Mountain Ranch Road, San Andreas, CA · (209) 754-3823
- Certified beds
- 99
- Residents per day
- 87
- Ownership
- For-Profit
- Chain
- Golden SNF Operations
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- July 1, 1977
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
-
Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in California.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among California homes
Golden San Andreas Care Center carries 128 inspection points. That is fewer than 26% of California's 1,154 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in California: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–33 pts
- 4★ 33–66 pts
- 3★ 66–96 pts
- 2★ 96–146 pts
- 1★ over 146 pts
Bars show every rated home in California by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
80 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (6)
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
-
G
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
-
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Everything else, by area of care
Quality of Life and Care19D
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide enough food/fluids to maintain a resident's health.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide safe, appropriate pain management for a resident who requires such services.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Resident Assessment and Care Planning11E
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Pharmacy Service10E
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
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.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Ensure medication error rates are not 5 percent or greater.
- E
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.
- D
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.
Infection Control9E
- E
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- E
Provide and implement an infection prevention and control program.
- D
Implement a program that monitors antibiotic use.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Resident Rights9E
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
- E
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Nutrition and Dietary6E
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Dispose of garbage and refuse properly.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Freedom from Abuse, Neglect, and Exploitation5E
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- D
Respond appropriately to all alleged violations.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- E
Respond appropriately to all alleged violations.
Nursing and Physician Services3E
- D
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- D
Observe each nurse aide's job performance and give regular training.
Environmental2D
- D
Keep all essential equipment working safely.
- D
Keep all essential equipment working safely.
Inspection history
2026-06-12
18 health deficiencies · 7 fire-safety deficiencies
Top issue: Pharmacy Service (5 deficiencies)
2025-02-06
22 health deficiencies · 6 fire-safety deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
2024-01-30
40 health deficiencies · 9 fire-safety deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 7 min of nursing staff time a day, 14 min of it from a registered nurse.
This home
4 h 7 min
California average
4 h 33 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 54% of nursing staff and 67% of registered nurses left in the past year, along with 1 administrator.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$66,534 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2024-10-15 | Fine | $14,293 |
| 2024-01-30 | Fine | $52,241 |
| 2024-01-30 | Payment Denial · 14 day denial | $0 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days1.2 pts better | 1.0 | 2.2 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days1.1 pts worse | 2.6 | 1.5 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine1.3 pts better | 100.0% | 98.7% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine2.1 pts better | 100.0% | 97.9% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.4 pts better | 1.2% | 1.6% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms7.2 pts better | 0.4% | 7.6% | 13.5% |
| Percentage of long-stay residents who lose too much weight0.8 pts better | 3.3% | 4.1% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication0.7 pts better | 13.0% | 13.7% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication6.6 pts better | 5.7% | 12.3% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.3 pts better | 0.0% | 0.3% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened15.3 pts worse | 24.2% | 8.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased7.3 pts worse | 17.5% | 10.2% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.7 pts better | 0.0% | 0.7% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.4 pts better | 0.8% | 1.2% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence15.2 pts worse | 25.0% | 9.8% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.6 pts worse | 5.9% | 4.3% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine3.9 pts better | 98.5% | 94.6% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit8.8 pts worse | 19.9% | 11.1% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.3 pts better | 0.0% | 1.3% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine6.1 pts better | 99.2% | 93.1% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission3.5 pts better | 19.1% | 22.6% | 23.4% |
·
Who owns and runs it
33 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Cafive Operations Holdings LLC | 5% Or Greater Direct Ownership Interest · Organization | 100% | 3 facilities |
| Ch Cafive Holdings LLC | 5% Or Greater Indirect Ownership Interest · Organization | 61% | 4 facilities |
| Barias, Karen | Managing Control - Governing Body · Individual | 0% | 4 facilities |
| Barias, Karen | Operational/Managerial Control · Individual | 0% | 4 facilities |
| Barias, Karen | Adp Of The SNF · Individual | 0% | 4 facilities |
| Cafive Opco Manager LLC | Operational/Managerial Control · Organization | 0% | 3 facilities |
| Cafive Opco Manager LLC | Adp Of The SNF · Organization | 0% | 3 facilities |
| Cafive SNF Consulting LLC | Operational/Managerial Control · Organization | 0% | 3 facilities |
| Cafive SNF Consulting LLC | Adp Of The SNF · Organization | 0% | 3 facilities |
| Couve Healthcare Consulting LLC | Operational/Managerial Control · Organization | 0% | 50 facilities |
| Couve Healthcare Consulting LLC | Adp Of The SNF · Organization | 0% | 50 facilities |
| Earl, Steven | Managing Control - Governing Body · Individual | 0% | 24 facilities |
| Earl, Steven | Operational/Managerial Control · Individual | 0% | 24 facilities |
| Earl, Steven | Adp Of The SNF · Individual | 0% | 24 facilities |
| Herzka, Yisroel | Adp Of The SNF · Individual | 0% | 75 facilities |
| Kelaita, Dean | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Kelaita, Dean | Adp Of The SNF · Individual | 0% | 1 facilities |
| Lichtenhan, Cynthia | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Lichtenhan, Cynthia | Adp Of The SNF · Individual | 0% | 1 facilities |
| Ruhl, Gina | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Ruhl, Gina | Adp Of The SNF · Individual | 0% | 1 facilities |
| San Andreas SNF Operations LLC | Operational/Managerial Control · Organization | 0% | 1 facilities |
| San Andreas SNF Operations LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| San Andreas SNF Realty LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Spielman, Shimon | Corporate Officer · Individual | 0% | 48 facilities |
| Spielman, Shimon | Operational/Managerial Control · Individual | 0% | 48 facilities |
| Spielman, Shimon | Adp Of The SNF · Individual | 0% | 48 facilities |
| Veritas Health Solutions LLC | Operational/Managerial Control · Organization | 0% | 8 facilities |
| Veritas Health Solutions LLC | Adp Of The SNF · Organization | 0% | 8 facilities |
| Witzcorp LLC | Adp Of The SNF · Organization | 0% | 8 facilities |
| Yenowitz, Yitzchok | Corporate Officer · Individual | 0% | 50 facilities |
| Yenowitz, Yitzchok | Operational/Managerial Control · Individual | 0% | 50 facilities |
| Yenowitz, Yitzchok | Adp Of The SNF · Individual | 0% | 50 facilities |
·
Fire safety
22 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Gas, Vacuum, and Electrical Systems10F
- E
Ensure proper usage of power strips and extension cords.
- D
Meet requirements for the use of electrical equipment.
- C
Have generator or other power source capable of supplying service within 10 seconds.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- D
Meet requirements for the use of electrical equipment.
- D
Have proper medical gas storage and administration areas.
- C
Have generator or other power source capable of supplying service within 10 seconds.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- D
Ensure proper usage of power strips and extension cords.
- D
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Smoke9E
- E
Inspect, test, and maintain automatic sprinkler systems.
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
- D
Install corridor and hallway doors that block smoke.
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D
Inspect, test, and maintain automatic sprinkler systems.
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
- D
Install corridor and hallway doors that block smoke.
Miscellaneous2E
- C
Have simulated fire drills held at unexpected times.
- E
Have simulated fire drills held at unexpected times.
Construction1D
- D
Use approved construction type or materials.
·
Other homes nearby
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Kit Carson Nursing & Rehabilitation Center
Jackson, CA · Eva Care Group · Special Focus
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 5 h 51 min
- Fines
- $28,327
-
Adventist Health Sonora - D/P SNF
Sonora, CA · Adventist Health
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 4 h 49 min
- Fines
- $0
-
Golden Sonora Care Center
Sonora, CA · Golden SNF Operations
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 4 h 5 min
- Fines
- $56,843