Medicare rates every nursing home from 1 to 5 stars. 5 is much above average, 1 is much below.
Inspection findings
Inspectors recorded 40 findings in the last three inspection cycles.
Each entry below is a requirement that inspectors found the home did not meet on that date, in the regulator's own English wording.
| Inspection date | Area | Requirement the home did not meet (official wording, in English) | Severity | Corrected |
|---|---|---|---|---|
| Aug 12, 2026 | Resident assessment and care planning | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (F0842) | No harm, but a risk of harm pattern · from a complaint | Corrected: Aug 19, 2026 |
| Jun 11, 2026 | Quality of life and care | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689) | Actual harm to a resident isolated · from a complaint | Corrected: Jul 6, 2026 |
| Jun 11, 2026 | Resident assessment and care planning | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F0656) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jul 6, 2026 |
| Feb 24, 2026 | Quality of life and care | Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F0684) | No harm, but a risk of harm isolated · from a complaint | Corrected: Mar 9, 2026 |
Earlier inspections (36)
| Inspection date | Area | Requirement the home did not meet (official wording, in English) | Severity | Corrected |
|---|---|---|---|---|
| Jan 28, 2026 | Food and nutrition | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. (F0808) | No harm, but a risk of harm isolated · from a complaint | Corrected: Feb 17, 2026 |
| Dec 12, 2025 | Building and environment | Make sure that a working call system is available in each resident's bathroom and bathing area. (F0919) | No harm, but a risk of harm pattern | Corrected: Dec 18, 2025 |
| Dec 12, 2025 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm isolated | Corrected: Dec 18, 2025 |
| Dec 12, 2025 | Food and nutrition | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F0812) | No harm, but a risk of harm pattern | Corrected: Dec 22, 2025 |
| Dec 12, 2025 | Quality of life and care | Provide for the safe, appropriate administration of IV fluids for a resident when needed. (F0694) | No harm, but a risk of harm isolated | Corrected: Dec 23, 2025 |
| Dec 12, 2025 | Quality of life and care | Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F0686) | No harm, but a risk of harm pattern | Corrected: Dec 16, 2025 |
| Dec 12, 2025 | Quality of life and care | Provide care and assistance to perform activities of daily living for any resident who is unable. (F0677) | No harm, but a risk of harm isolated | Corrected: Dec 17, 2025 |
| Dec 12, 2025 | Resident assessment and care planning | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (F0657) | No harm, but a risk of harm isolated | Corrected: Dec 26, 2025 |
| Dec 12, 2025 | Abuse, neglect and exploitation | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. (F0605) | No harm, but a risk of harm isolated | Corrected: Dec 26, 2025 |
| Dec 12, 2025 | Resident rights | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F0550) | No harm, but a risk of harm isolated | Corrected: Dec 26, 2025 |
| Oct 25, 2024 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm widespread | Corrected: Nov 17, 2024 |
| Oct 25, 2024 | Food and nutrition | Dispose of garbage and refuse properly. (F0814) | No harm, but a risk of harm pattern | Corrected: Nov 17, 2024 |
| Oct 25, 2024 | Food and nutrition | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F0812) | No harm, but a risk of harm pattern | Corrected: Nov 17, 2024 |
| Oct 25, 2024 | Pharmacy and medications | Ensure that residents are free from significant medication errors. (F0760) | No harm, but a risk of harm isolated | Corrected: Nov 17, 2024 |
| Oct 25, 2024 | Pharmacy and medications | Ensure medication error rates are not 5 percent or greater. (F0759) | No harm, but a risk of harm pattern | Corrected: Nov 17, 2024 |
| Oct 25, 2024 | Pharmacy and medications | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F0755) | No harm, but a risk of harm isolated | Corrected: Nov 17, 2024 |
| Oct 25, 2024 | Nursing and physician services | Post nurse staffing information every day. (F0732) | No harm, minimal risk pattern | Corrected: Nov 17, 2024 |
| Oct 25, 2024 | Quality of life and care | Provide safe and appropriate respiratory care for a resident when needed. (F0695) | No harm, but a risk of harm isolated | Corrected: Nov 17, 2024 |
| Oct 25, 2024 | Quality of life and care | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689) | No harm, but a risk of harm pattern | Corrected: Nov 17, 2024 |
| Oct 25, 2024 | Quality of life and care | Provide care and assistance to perform activities of daily living for any resident who is unable. (F0677) | No harm, but a risk of harm isolated | Corrected: Nov 17, 2024 |
| Oct 25, 2024 | Abuse, neglect and exploitation | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. (F0604) | No harm, but a risk of harm isolated | Corrected: Nov 17, 2024 |
| Oct 25, 2024 | Resident rights | 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. (F0578) | No harm, but a risk of harm isolated | Corrected: Nov 17, 2024 |
| Oct 25, 2024 | Resident rights | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F0550) | No harm, but a risk of harm isolated | Corrected: Nov 17, 2024 |
| Aug 20, 2024 | Pharmacy and medications | 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. (F0758) | No harm, but a risk of harm pattern · from a complaint | Corrected: Sep 13, 2024 |
| Aug 20, 2024 | Quality of life and care | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689) | Actual harm to a resident isolated · from a complaint | Corrected: Sep 13, 2024 |
| Aug 20, 2024 | Resident assessment and care planning | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F0656) | No harm, but a risk of harm isolated · from a complaint | Corrected: Sep 13, 2024 |
| Aug 20, 2024 | Abuse, neglect and exploitation | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. (F0604) | No harm, but a risk of harm isolated · from a complaint | Corrected: Sep 13, 2024 |
| Nov 19, 2023 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm pattern | Corrected: Dec 13, 2023 |
| Nov 19, 2023 | Administration | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. (F0849) | No harm, but a risk of harm pattern | Corrected: Dec 13, 2023 |
| Nov 19, 2023 | Food and nutrition | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F0812) | No harm, but a risk of harm pattern | Corrected: Dec 13, 2023 |
| Nov 19, 2023 | Pharmacy and medications | 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. (F0761) | No harm, but a risk of harm isolated | Corrected: Dec 13, 2023 |
| Nov 19, 2023 | Quality of life and care | Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F0686) | No harm, but a risk of harm pattern | Corrected: Dec 13, 2023 |
| Nov 19, 2023 | Quality of life and care | Provide care and assistance to perform activities of daily living for any resident who is unable. (F0677) | No harm, but a risk of harm isolated | Corrected: Dec 13, 2023 |
| Nov 19, 2023 | Abuse, neglect and exploitation | Develop and implement policies and procedures to prevent abuse, neglect, and theft. (F0607) | No harm, but a risk of harm isolated · from a complaint | Corrected: Dec 13, 2023 |
| Nov 19, 2023 | Resident rights | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (F0580) | No harm, but a risk of harm isolated | Corrected: Dec 13, 2023 |
| Nov 19, 2023 | Resident rights | 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. (F0578) | No harm, but a risk of harm isolated | Corrected: Dec 13, 2023 |
Fines and payment denials
No federal fines or payment denials in the last three years.
Staffing
| Nurse staff hours per resident per day | 4.28 | California median: 4.27 |
| Registered nurse hours per resident per day | 0.55 | California median: 0.52 |
| Nurse staff hours on weekends | 4.03 | California median: 3.85 |
| Nursing staff who left within a year | 26.1% | California median: 36.0% |
About this home
| Beds | 106 |
| Residents per day, average | 51.7 |
| Ownership | Non-profit, corporation |
| Legal business name | Hollenbeck Palms |
| In Medicare/Medicaid since | Jan 1, 1967 |
| Part of a continuing care retirement community | Yes |
Questions to ask when you call
- What was corrected after the last inspection?
- How many staff work at night and on weekends?
- Does anyone on staff speak my relative's language?
- May I visit at any time, without an appointment?
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