Sonoma Post Acute

• Star rating

  The CMS overall star rating changed from 4 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5.

• Fine

  CMS changed the fine from April 16, 2026 from $18,470 to $12,006.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on July 17, 2026.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on July 17, 2026.

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CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

118 of 1,165 California homes (10%) got a citation at the actual harm level in 2026.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on May 13, 2026.

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CMS lists this as a standard inspection.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on May 8, 2026.

  CMS has cited this home for F0812 2 times since 2022.

• Citation F0908. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Keep all essential equipment working safely.

  CMS lists it as corrected on May 8, 2026.

• Citation F0577. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

  CMS lists it as corrected on May 8, 2026.

• Citation F0699. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide care or services that was trauma informed and/or culturally competent.

  CMS lists it as corrected on May 8, 2026.

• Citation F0725. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  CMS lists it as corrected on May 8, 2026.

  CMS has cited this home for F0725 2 times since 2022.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on May 8, 2026.

  CMS has cited this home for F0804 2 times since 2022.

• Citation F0685. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Assist a resident in gaining access to vision and hearing services.

  CMS lists it as corrected on May 8, 2026.

• Citation F0791. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide or obtain dental services for each resident.

  CMS lists it as corrected on May 8, 2026.

• Citation F0802. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

  CMS lists it as corrected on May 8, 2026.

  CMS has cited this home for F0802 2 times since 2022.

• Citation F0881. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Implement a program that monitors antibiotic use.

  CMS lists it as corrected on May 8, 2026.

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CMS lists this as a standard inspection.

• Citation E0030. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: List the names and contact information of those in the facility.

  CMS lists it as corrected on May 21, 2026.

• Citation E0039. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on May 21, 2026.

  CMS has cited this home for E0039 2 times since 2025.

• Citation K0291. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install emergency lighting that can last at least 1 1/2 hours.

  CMS lists it as corrected on May 21, 2026.

  CMS has cited this home for K0291 2 times since 2025.

• Citation K0341. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install a fire alarm system that can be heard throughout the facility.

  CMS lists it as corrected on May 21, 2026.

• Citation K0355. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Properly select, install, inspect, or maintain portable fire extinguishes.

  CMS lists it as corrected on May 21, 2026.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on May 21, 2026.

  CMS has cited this home for K0918 2 times since 2025.

• Citation K0324. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on May 21, 2026.

• Citation K0325. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have properly installed hallway dispensers for alcohol-based hand rub.

  CMS lists it as corrected on May 21, 2026.

• Citation K0711. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide a written emergency evacuation plan.

  CMS lists it as corrected on May 21, 2026.

  CMS has cited this home for K0711 2 times since 2022.

• Citation K0919. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Meet requirements for the use of electrical equipment.

  CMS lists it as corrected on May 21, 2026.

  CMS has cited this home for K0919 2 times since 2022.

• Citation K0920. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on May 21, 2026.

  CMS has cited this home for K0920 2 times since 2025.

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CMS fine of $12,006 on April 16, 2026.

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• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

• Health citation

  CMS removed citation F0686 from the health inspection on May 16, 2025.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

CMS lists this as a complaint inspection.

• Citation F0627. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

  CMS lists it as corrected on January 5, 2026.

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CMS lists this as a complaint inspection.

• Citation F0606. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

  CMS lists it as corrected on August 14, 2025.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on August 14, 2025.

  CMS has cited this home for F0658 5 times since 2022.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

CMS lists this as a complaint inspection.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on July 31, 2025.

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CMS lists this as a complaint inspection.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on August 8, 2025.

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CMS lists this as a complaint inspection.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on June 16, 2025.

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• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5.

CMS lists this as a complaint inspection.

• Citation F0622. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on April 7, 2025.

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• Star rating

  The CMS staffing star rating changed from 2 of 5 to 1 of 5.

CMS lists this as a complaint inspection.

• Citation F0576. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure residents have reasonable access to and privacy in their use of communication methods.

  CMS lists it as corrected on February 5, 2025.

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CMS lists this as a standard inspection.

• Citation E0039. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on March 3, 2025.

• Citation K0345. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on February 20, 2025.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on February 20, 2025.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on January 16, 2025.

• Citation K0291. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install emergency lighting that can last at least 1 1/2 hours.

  CMS lists it as corrected on January 16, 2025.

• Citation K0363. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on January 16, 2025.

  CMS has cited this home for K0363 2 times since 2022.

• Citation K0920. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on January 16, 2025.

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• Ownership

  CMS lists this home under a new chain.

CMS lists this as a complaint inspection.

• Citation F0697. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.

  CMS lists it as corrected on June 20, 2024.

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• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

• Health citation

  CMS removed citation F0725 from the health inspection on January 17, 2023.

CMS lists this as a standard inspection.

Severity L is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

8 of 1,165 California homes (under 1%) got a citation at the immediate jeopardy level in 2022.

• Citation F0695. Severity L: immediate jeopardy, widespread.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on April 24, 2022.

• Citation F0679. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide activities to meet all resident's needs.

  CMS lists it as corrected on April 24, 2022.

• Citation F0801. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: 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.

  CMS lists it as corrected on April 24, 2022.

• Citation F0802. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

  CMS lists it as corrected on April 24, 2022.

• Citation F0656. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on April 24, 2022.

• Citation F0658. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on April 24, 2022.

• Citation F0692. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on April 24, 2022.

• Citation F0693. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

  CMS lists it as corrected on April 24, 2022.

• Citation F0725. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  CMS lists it as corrected on April 24, 2022.

• Citation F0726. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on April 24, 2022.

• Citation F0755. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on April 24, 2022.

• Citation F0756. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  CMS lists it as corrected on April 24, 2022.

• Citation F0759. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on April 24, 2022.

• Citation F0760. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that residents are free from significant medication errors.

  CMS lists it as corrected on April 24, 2022.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on April 24, 2022.

• Citation F0805. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

  CMS lists it as corrected on April 24, 2022.

• Citation F0806. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

  CMS lists it as corrected on April 24, 2022.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on April 24, 2022.

• Citation F0645. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: PASARR screening for Mental disorders or Intellectual Disabilities

  CMS lists it as corrected on April 24, 2022.

• Citation F0810. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide special eating equipment and utensils for residents who need them and appropriate assistance.

  CMS lists it as corrected on April 24, 2022.

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CMS lists this as a standard inspection.

• Citation E0009. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Include a process for Emergency Preparedness collaboration.

  CMS lists it as corrected on April 29, 2022.

• Citation E0018. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Establish procedures for tracking staff and patients during an emergency.

  CMS lists it as corrected on April 29, 2022.

• Citation E0022. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Establish policies and procedures for sheltering.

  CMS lists it as corrected on April 29, 2022.

• Citation E0023. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Establish policies and procedures for medical documentation.

  CMS lists it as corrected on April 29, 2022.

• Citation E0024. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Establish policies and procedures for volunteers.

  CMS lists it as corrected on April 29, 2022.

• Citation E0031. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide emergency officials' contact information.

  CMS lists it as corrected on April 29, 2022.

• Citation E0032. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide primary/alternate means for communication.

  CMS lists it as corrected on April 29, 2022.

• Citation E0033. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Establish methods for sharing information.

  CMS lists it as corrected on April 29, 2022.

• Citation E0034. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide a means of sharing information on occupancy/needs.

  CMS lists it as corrected on April 29, 2022.

• Citation E0035. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide family notifications of emergency plan.

  CMS lists it as corrected on April 29, 2022.

• Citation E0036. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Establish emergency prep training and testing.

  CMS lists it as corrected on April 29, 2022.

• Citation K0161. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Use approved construction type or materials.

  CMS lists it as corrected on April 29, 2022.

• Citation K0363. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on April 29, 2022.

• Citation K0711. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide a written emergency evacuation plan.

  CMS lists it as corrected on April 29, 2022.

• Citation K0712. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on April 29, 2022.

• Citation K0919. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Meet requirements for the use of electrical equipment.

  CMS lists it as corrected on April 29, 2022.

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