Golden San Andreas Care Center
900 Mountain Ranch Road · San Andreas, CA · 95249 · 2097543823
99 certified beds For profit - Limited Liability company Chain: Golden SNF Operations
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $14,293 in fines in the last 24 months.
- 5 citations involved actual harm to residents.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 3 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 4.16 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.32 | 0.55–0.75 |
| Weekend hours / resident-day | 3.66 | ≈ weekday level |
| Nursing turnover / year | 53% | median 45% |
| Fines (3-yr window) | 3 · $91,172 |
Inspection citations (85 in the current record)
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Potential for harm · D July 1, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected July 25, 2025 · Quality of Life and Care
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Potential for harm · D May 22, 2025 · found via complaint
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 May 28, 2025 · Quality of Life and Care
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Potential for harm · D May 22, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 28, 2025 · Quality of Life and Care
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Potential for harm · E May 22, 2025 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected May 28, 2025 · Resident Assessment and Care Planning
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Actual harm · G May 13, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected June 13, 2025 · Quality of Life and Care
-
Potential for harm · D February 6, 2025
Reasonably accommodate the needs and preferences of each resident.
Corrected February 26, 2025 · Resident Rights
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Potential for harm · E February 6, 2025
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.
Corrected February 26, 2025 · Resident Rights
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Potential for harm · E February 6, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected February 26, 2025 · Resident Assessment and Care Planning
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Potential for harm · D February 6, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected February 26, 2025 · Quality of Life and Care
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Potential for harm · D February 6, 2025
Provide enough food/fluids to maintain a resident's health.
Corrected February 26, 2025 · Quality of Life and Care
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Potential for harm · D February 6, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected February 26, 2025 · Quality of Life and Care
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Potential for harm · D February 6, 2025
Provide safe, appropriate pain management for a resident who requires such services.
Corrected February 26, 2025 · Quality of Life and Care
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Potential for harm · D February 6, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected February 26, 2025 · Pharmacy Service
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Potential for harm · E February 6, 2025
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected February 26, 2025 · Nutrition and Dietary
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Potential for harm · E February 6, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected February 26, 2025 · Nutrition and Dietary
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Potential for harm · D February 6, 2025
Dispose of garbage and refuse properly.
Corrected February 26, 2025 · Nutrition and Dietary
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Potential for harm · D February 6, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected February 26, 2025 · Resident Assessment and Care Planning
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Potential for harm · E February 6, 2025
Provide and implement an infection prevention and control program.
Corrected February 26, 2025 · Infection Control
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Potential for harm · D February 6, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected February 26, 2025 · Infection Control
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Potential for harm · D February 6, 2025
Keep all essential equipment working safely.
Corrected February 26, 2025 · Environmental
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Potential for harm · D January 21, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 22, 2025 · Quality of Life and Care
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Actual harm · G October 15, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected November 22, 2024 · Quality of Life and Care
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Potential for harm · D March 15, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected March 15, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D March 15, 2024 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected March 15, 2024 · Quality of Life and Care
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Potential for harm · D March 15, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected March 15, 2024 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| October 15, 2024 | Fine | $14,293 |
| January 30, 2024 | Fine | $52,241 |
| January 30, 2024 | Payment Denial | 14 days |
| October 3, 2023 | Fine | $24,638 |
Better-scoring options nearby
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 056132 · certified since July 1, 1977. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.