★★★★★Overall Medicare rating
★★★★★Health inspections
★★★★★Staffing
★★★★★Quality measures
Medicare rates every nursing home from 1 to 5 stars. 5 is much above average, 1 is much below.
Findings, latest cycle25
Findings with harm or immediate jeopardy, 3 cycles1
Fines, 3 years$8,425
Beds145
Inspection findings
Inspectors recorded 81 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 |
|---|---|---|---|---|
| Jul 29, 2026 | 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 · from a complaint | Corrected: Aug 14, 2026 |
| Jul 8, 2026 | Quality of life and care | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (F0690) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jul 23, 2026 |
| Feb 18, 2026 | Building and environment | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. (F0925) | No harm, but a risk of harm isolated | Corrected: Mar 13, 2026 |
| Feb 18, 2026 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm pattern | Corrected: Mar 13, 2026 |
| Feb 18, 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, minimal risk pattern | Corrected: Mar 13, 2026 |
| Feb 18, 2026 | 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: Mar 13, 2026 |
| Feb 18, 2026 | Food and nutrition | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. (F0804) | No harm, but a risk of harm isolated | Corrected: Mar 13, 2026 |
| Feb 18, 2026 | 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: Mar 13, 2026 |
| Feb 18, 2026 | Pharmacy and medications | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (F0756) | No harm, but a risk of harm isolated | Corrected: Mar 13, 2026 |
| Feb 18, 2026 | 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: Mar 13, 2026 |
| Feb 18, 2026 | Nursing and physician services | Observe each nurse aide's job performance and give regular training. (F0730) | No harm, minimal risk pattern | Corrected: Mar 13, 2026 |
| Feb 18, 2026 | Nursing and physician services | 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. (F0726) | No harm, but a risk of harm isolated | Corrected: Mar 13, 2026 |
| Feb 18, 2026 | Quality of life and care | Provide safe and appropriate respiratory care for a resident when needed. (F0695) | No harm, but a risk of harm pattern | Corrected: Mar 13, 2026 |
| Feb 18, 2026 | Quality of life and care | 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. (F0693) | No harm, but a risk of harm isolated | Corrected: Mar 13, 2026 |
| Feb 18, 2026 | Quality of life and care | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (F0690) | No harm, but a risk of harm isolated | Corrected: Mar 13, 2026 |
| Feb 18, 2026 | Quality of life and care | Provide appropriate foot care. (F0687) | No harm, but a risk of harm isolated | Corrected: Mar 13, 2026 |
| Feb 18, 2026 | Quality of life and care | Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F0686) | No harm, minimal risk pattern | Corrected: Mar 13, 2026 |
| Feb 18, 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 pattern | Corrected: Mar 13, 2026 |
| Feb 18, 2026 | 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: Mar 13, 2026 |
| Feb 18, 2026 | Resident rights | 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. (F0584) | No harm, but a risk of harm isolated | Corrected: Mar 13, 2026 |
| Feb 18, 2026 | Resident rights | Keep residents' personal and medical records private and confidential. (F0583) | No harm, but a risk of harm isolated | Corrected: Mar 13, 2026 |
| Feb 18, 2026 | Resident rights | Allow residents to self-administer drugs if determined clinically appropriate. (F0554) | No harm, but a risk of harm isolated | Corrected: Mar 13, 2026 |
Earlier inspections (59)
| Inspection date | Area | Requirement the home did not meet (official wording, in English) | Severity | Corrected |
|---|---|---|---|---|
| Nov 26, 2025 | 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, minimal risk pattern · from a complaint | Corrected: Dec 8, 2025 |
| Nov 26, 2025 | 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: Dec 8, 2025 |
| Nov 10, 2025 | 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: Dec 23, 2025 |
| Sep 18, 2025 | 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: Oct 10, 2025 |
| Aug 6, 2025 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm isolated · from a complaint | Corrected: Aug 13, 2025 |
| Jul 10, 2025 | Nursing and physician services | 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. (F0726) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jul 30, 2025 |
| May 14, 2025 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jun 4, 2025 |
| May 14, 2025 | 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, minimal risk pattern · from a complaint | Corrected: Jun 4, 2025 |
| May 14, 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 isolated · from a complaint | Corrected: Jun 4, 2025 |
| May 14, 2025 | 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: Jun 4, 2025 |
| Feb 28, 2025 | 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 isolated · from a complaint | Corrected: Mar 20, 2025 |
| Feb 28, 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 isolated · from a complaint | Corrected: Mar 20, 2025 |
| Jan 7, 2025 | Quality of life and care | Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F0684) | No harm, minimal risk pattern · from a complaint | Corrected: Jan 28, 2025 |
| Nov 15, 2024 | Infection control | Implement a program that monitors antibiotic use. (F0881) | No harm, but a risk of harm isolated · from a complaint | Corrected: Dec 14, 2024 |
| Nov 15, 2024 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm isolated | Corrected: Dec 14, 2024 |
| Nov 15, 2024 | 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 isolated | Corrected: Dec 14, 2024 |
| Nov 15, 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: Dec 14, 2024 |
| Nov 15, 2024 | Administration | Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. (F0773) | No harm, but a risk of harm isolated | Corrected: Dec 14, 2024 |
| Nov 15, 2024 | 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 14, 2024 |
| Nov 15, 2024 | Pharmacy and medications | Ensure medication error rates are not 5 percent or greater. (F0759) | No harm, but a risk of harm isolated | Corrected: Dec 14, 2024 |
| Nov 15, 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 isolated | Corrected: Dec 14, 2024 |
| Nov 15, 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: Dec 14, 2024 |
| Nov 15, 2024 | Quality of life and care | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. (F0700) | No harm, but a risk of harm isolated | Corrected: Dec 14, 2024 |
| Nov 15, 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: Dec 14, 2024 |
| Nov 15, 2024 | Quality of life and care | 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. (F0693) | No harm, but a risk of harm isolated | Corrected: Dec 14, 2024 |
| Nov 15, 2024 | Quality of life and care | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (F0690) | No harm, but a risk of harm isolated | Corrected: Dec 14, 2024 |
| Nov 15, 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 isolated | Corrected: Dec 14, 2024 |
| Nov 15, 2024 | Quality of life and care | Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F0686) | No harm, but a risk of harm isolated | Corrected: Dec 14, 2024 |
| Nov 15, 2024 | 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 | Corrected: Dec 14, 2024 |
| Nov 15, 2024 | Resident rights | 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. (F0584) | No harm, but a risk of harm isolated | Corrected: Dec 14, 2024 |
| Nov 15, 2024 | 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 14, 2024 |
| Nov 15, 2024 | Resident rights | Reasonably accommodate the needs and preferences of each resident. (F0558) | No harm, but a risk of harm isolated | Corrected: Dec 14, 2024 |
| Nov 15, 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, minimal risk pattern · from a complaint | Corrected: Dec 14, 2024 |
| Aug 1, 2024 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, minimal risk pattern · from a complaint | Corrected: Aug 12, 2024 |
| May 30, 2024 | Resident rights | Reasonably accommodate the needs and preferences of each resident. (F0558) | No harm, minimal risk pattern · from a complaint | Corrected: Jun 14, 2024 |
| Mar 21, 2024 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm isolated · from a complaint | Corrected: Apr 12, 2024 |
| Mar 21, 2024 | Pharmacy and medications | Ensure each resident’s drug regimen must be free from unnecessary drugs. (F0757) | No harm, but a risk of harm isolated · from a complaint | Corrected: Apr 13, 2024 |
| Mar 21, 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: Apr 13, 2024 |
| Mar 12, 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 isolated · from a complaint | Corrected: Mar 27, 2024 |
| Jan 24, 2024 | 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 isolated · from a complaint | Corrected: Feb 15, 2024 |
| Jan 24, 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 · from a complaint | Corrected: Feb 15, 2024 |
| Jan 24, 2024 | 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: Feb 15, 2024 |
| Dec 13, 2023 | 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 · from a complaint | Corrected: Dec 29, 2023 |
| Dec 13, 2023 | 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 isolated · from a complaint | Corrected: Dec 29, 2023 |
| Nov 17, 2023 | Pharmacy and medications | Ensure each resident’s drug regimen must be free from unnecessary drugs. (F0757) | No harm, but a risk of harm isolated · from a complaint | Corrected: Dec 5, 2023 |
| Oct 23, 2023 | Resident assessment and care planning | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. (F0661) | No harm, but a risk of harm isolated · from a complaint | Corrected: Nov 7, 2023 |
| May 16, 2022 | Building and environment | Keep all essential equipment working safely. (F0908) | No harm, but a risk of harm isolated | Corrected: Jun 16, 2022 |
| May 16, 2022 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm isolated | Corrected: Jun 16, 2022 |
| May 16, 2022 | 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 isolated | Corrected: Jun 16, 2022 |
| May 16, 2022 | 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 isolated | Corrected: Jun 16, 2022 |
| May 16, 2022 | 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: Jun 16, 2022 |
| May 16, 2022 | Quality of life and care | Provide safe, appropriate dialysis care/services for a resident who requires such services. (F0698) | No harm, but a risk of harm isolated | Corrected: Jun 16, 2022 |
| May 16, 2022 | Quality of life and care | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (F0690) | No harm, but a risk of harm isolated | Corrected: Jun 16, 2022 |
| May 16, 2022 | 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 isolated | Corrected: Jun 16, 2022 |
| May 16, 2022 | Quality of life and care | Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F0686) | No harm, but a risk of harm isolated | Corrected: Jun 16, 2022 |
| May 16, 2022 | 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 | Corrected: Jun 16, 2022 |
| May 16, 2022 | 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 | Corrected: Jun 16, 2022 |
| May 16, 2022 | Resident rights | Reasonably accommodate the needs and preferences of each resident. (F0558) | No harm, but a risk of harm isolated | Corrected: Jun 16, 2022 |
| May 16, 2022 | Resident rights | Ensure that residents are fully informed and understand their health status, care and treatments. (F0552) | No harm, but a risk of harm isolated | Corrected: Jun 16, 2022 |
Fines and payment denials
Federal fines in the last three years: $8,425 (1). Payment denials: 1.
| Date | Type | Amount |
|---|---|---|
| Nov 10, 2025 | Fine | $8,425 |
| Nov 10, 2025 | Payment denial | 13 days |
Staffing
| Nurse staff hours per resident per day | 5.03 | California median: 4.27 |
| Registered nurse hours per resident per day | 0.52 | California median: 0.52 |
| Nurse staff hours on weekends | 4.55 | California median: 3.85 |
| Nursing staff who left within a year | no data | California median: 36.0% |
About this home
| Beds | 145 |
| Residents per day, average | 137.1 |
| Ownership | For-profit, corporation |
| Legal business name | Hollyleaf Healthcare, Inc. |
| Chain | The Ensign Group (347 homes) |
| In Medicare/Medicaid since | Dec 7, 1987 |
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?
Source. Medicare Care Compare (CMS Provider Data), data dated Oct 1, 2026. Open this home on Medicare.gov
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