Santa Rosa, CA
2-star overall rating with 1-star inspections with $107,746 in total fines with 18 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
4650 Hoen Avenue, Santa Rosa, CA
(707) 546-0471
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
99
Certified beds
Average residents
95
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1967-11-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.67
Registered nurse staffing
LPN hours / resident day
0.89
Licensed practical nurse staffing
Aide hours / resident day
2.41
Nurse aide staffing
Weekend hours
3.43
Weekend nurse staffing
RN turnover
27%
Annual RN turnover
Total nurse turnover
36%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.3
1 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 |
| 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 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
98.2%
0.6 pts worse
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
1.6%
0.3 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
6.8%
5.6 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 1.8% |
4.1%
2.3 pts better
|
5.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.8% |
13.7%
5.1 pts worse
|
19.6%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 12.2% |
14.2%
2 pts better
|
16.7%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.3% |
11.0%
1.3 pts worse
|
16.3%
4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.8% |
10.7%
4.9 pts better
|
14.9%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.2%
0.9 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.4% |
10.9%
7.5 pts worse
|
19.8%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
4.7%
0.3 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
94.0%
3.9 pts better
|
81.7%
16.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.8% |
11.2%
8.6 pts worse
|
12.0%
7.8 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
93.2%
2.3 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.2% |
23.2%
2 pts worse
|
23.9%
1.3 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Nutrition and Dietary (3 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-10-23
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-11-30
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-23
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-10-23
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-10-23
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-10-23
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-30
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-30
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 2024-03-30
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-30
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-03-30
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-30
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2021-07-01
Fire Safety
Implement emergency and standby power systems.
Corrected 2021-07-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-07-01
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-07-01
Fire Safety
Use approved construction type or materials.
Corrected 2021-07-01
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2021-07-01
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2021-07-01
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-07-01
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-07-01
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-07-01
Inspection history
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-01-14
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-10-06
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2025-10-06
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-06
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-10-06
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-10-06
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-06
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-10-06
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-06
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-10-06
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-10-06
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-10-05
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-05-12
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-12
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-05-16
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-05-16
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-05-02
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-04-07
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2025-03-11
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-02-13
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-03
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-10-23
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-10-23
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-11-06
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-09-15
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-07-12
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-07-12
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2024-07-12
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-07-12
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-16
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-16
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2024-01-13
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-08
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-01-08
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-31
Health
Keep all essential equipment working safely.
Corrected 2023-12-30
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-14
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-13
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-07-28
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 2023-08-05
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-05
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-05-11
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-11
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-04-28
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-03-29
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-03-29
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-03
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-03
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-05-25
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-05-25
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2021-05-25
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-05-25
Health
Provide activities to meet all resident's needs.
Corrected 2021-05-25
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-05-25
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 2021-05-25
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-05-25
Health
Provide and implement an infection prevention and control program.
Corrected 2021-05-25
Penalties and ownership
Fine · fine $97,580
Fine
Payment Denial · denial start 2026-01-10 · 4 days
4 day denial
Fine · fine $10,166
Fine
5% Or Greater Direct Ownership Interest · Organization
Corporate Officer · Individual
Operational/Managerial Control · Individual
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Contracted Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Santa Rosa, CA
5-star overall rating with 5-star inspections with $3,145 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Santa Rosa, CA
3-star overall rating with 2-star inspections with abuse icon flag with 19 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Santa Rosa, CA
5-star overall rating with 3-star inspections with $44,730 in total fines with 16 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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