San Pablo Healthcare & Wellness Center
13328 San Pablo Avenue · San Pablo, CA · 94806 · 5102353720
108 certified beds For profit - Corporation Chain: Sol Healthcare
Why this verdict
- Carries CMS’s abuse warning icon.
- Staffing levels are well below research benchmarks for safe care.
- 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
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
Cited under the freedom-from-abuse rule
Cited 3 times under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
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: 2 of 5 Staffing: 1 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | — | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | — | 0.55–0.75 |
| Weekend hours / resident-day | — | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | 1 · $10,036 |
Inspection citations (43 in the current record)
-
Potential for harm · D March 30, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 16, 2026 · Quality of Life and Care
-
Potential for harm · D February 19, 2026 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected March 18, 2026 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D February 19, 2026 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected March 18, 2026 · Resident Assessment and Care Planning
-
Potential for harm · E February 2, 2026 · found via complaint
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected February 27, 2026 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D December 30, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected January 16, 2026 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D June 26, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected July 23, 2025 · Resident Rights
-
Potential for harm · D June 26, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected July 23, 2025 · Resident Assessment and Care Planning
-
Potential for harm · E June 26, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected July 23, 2025 · Resident Assessment and Care Planning
-
Potential for harm · D June 26, 2025
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.
Corrected July 23, 2025 · Quality of Life and Care
-
Potential for harm · E June 26, 2025
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected July 23, 2025 · Nutrition and Dietary
-
Potential for harm · F June 26, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected July 23, 2025 · Nutrition and Dietary
-
No harm found · C June 26, 2025
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected July 23, 2025 · Environmental
-
Potential for harm · D June 17, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected June 30, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D April 1, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected April 17, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D April 1, 2025 · found via complaint
Provide or get specialized rehabilitative services as required for a resident.
Corrected April 17, 2025 · Quality of Life and Care
-
Potential for harm · D January 2, 2025 · found via complaint
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected January 3, 2025 · Resident Rights
-
Potential for harm · D January 2, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected January 3, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D January 2, 2025 · found via complaint
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected January 3, 2025 · Environmental
-
Potential for harm · D October 9, 2024 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected October 25, 2024 · Quality of Life and Care
-
Potential for harm · D October 9, 2024 · found via complaint
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected October 25, 2024 · Environmental
-
Potential for harm · D October 4, 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 October 18, 2024 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · E July 3, 2024 · found via complaint
Provide and implement an infection prevention and control program.
Corrected July 18, 2024 · Infection Control
-
Potential for harm · D June 20, 2024 · found via complaint
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected July 8, 2024 · Nursing and Physician Services
-
Potential for harm · D April 24, 2024 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected May 8, 2024 · Quality of Life and Care
-
Potential for harm · D April 24, 2024 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected May 8, 2024 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| February 2, 2024 | Fine | $10,036 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 056359 · certified since September 29, 1972. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.