Golden San Andreas Care Center
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 42 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Low overall rating (1/5 stars)
- Above-median deficiencies (20 vs median 13.0)
- High RN turnover (60%)
Bottom 25% in CA · Critically understaffed (RN) · Worst in GOLDEN SNF OPERATIONS chain · $91,172 in fines
What this means for your family
The facility offers exceptional physical therapy and a friendly atmosphere for social activities like Bingo. However, you must be extremely vigilant regarding medication accuracy and facility hygiene, as multiple reviewers have reported serious issues with theft, odors, and improper medication changes.
Google Reviews
Google Reviews
42 reviews on Google“Families looking for rehabilitation services will find a highly praised therapy department and a staff that many describe as compassionate and professional. However, there are serious, recurring allegations regarding cleanliness, unpleasant odors, and instances of severe medical mismanagement or theft that require close investigation.”
Quality Themes
Tap a score for detailsStrengths
- Excellent rehabilitation and physical therapy
- Compassionate and friendly nursing staff
- Engaging social activities like Bingo
- Welcoming atmosphere for family members
Concerns
- Issues with facility cleanliness and unpleasant odors (mentioned by 3 reviewers)
- Staffing shortages and understaffing (mentioned by 2 reviewers)
- Inconsistent medication management (mentioned by 2 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 45 analyzed
How They Respond to Reviews
The owner uses highly templated responses that vary based on star rating. Positive reviews receive repetitive, short acknowledgments, while negative reviews are met with standardized scripts inviting the reviewer to call a specific phone number.
Questions for Your Tour
- 1We've heard wonderful things about the physical therapy and rehab programs here; could you tell us more about how that works for new residents?
- 2It's great to see how much you engage with families in your responses; how often do you encourage family members to visit and participate in the community?
- 3What kind of daily social activities, like Bingo or group outings, are currently available to keep residents engaged?
- 4Could you walk us through your specific protocols for medication administration to ensure everything is handled accurately and timely?
- 5What steps are being taken to ensure the facility remains fresh, clean, and well-maintained for the residents?
- 6In the event of a medical emergency during the night, what is the immediate process for getting a doctor or supervisor involved?
Personalized based on this facility's data
Key Review Excerpts
“His care was outstanding! The place is well staffed. Everyone is very friendly and upbeat. The food was excellent and very nutritious.”
“The staff were kind, caring and really worked with him to regain his strength. The facility was clean and smelled nice.”
“After an illegal search in my purse a so-called nurse had a doctor who I never met take me off of 2 of my medications which put me in the emergency room.”
Staffing
Staffing Hours
per resident/day · Medicare 2026RN hours are below the national benchmark. RNs handle complex medical needs and medication, so ask about coverage during your visit.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
10
measures
6
measures
1
measures
Residents whose bladder or bowel control got worse
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents whose walking got worse
Residents on antipsychotic medication
Residents vaccinated for pneumonia
Residents needing more daily help over time
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
Golden San Andreas Care Center has a concerning pattern of repeated safety violations, with families filing 30 complaint reports triggering inspections. The most persistent problems involve accident prevention and safety supervision, medication management, and infection control—all appearing across multiple years despite reported corrections. Recent violations in 2024-2025 suggest ongoing challenges, including a serious neglect issue requiring immediate correction, indicating systemic problems that may not be fully resolved.
Jul 1, 2025Complaint1
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
May 22, 2025Complaint3
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Quality of Life and Care Deficiencies
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
May 13, 2025Complaint1
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Feb 6, 2025Routine21
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Resident Rights Deficiencies
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.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Environmental Deficiencies
Keep all essential equipment working safely.
Construction Deficiencies
Use approved construction type or materials.
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Gas, Vacuum, and Electrical Systems Deficiencies
Meet requirements for the use of electrical equipment.
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Jan 21, 2025Complaint1
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Oct 15, 2024Complaint1
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Federal Penalties
Fine
Oct 15, 2024
$14,293
Fine
Jan 30, 2024
$52,241
Payment Denial
Jan 30, 2024
14-day denial
Fine
Oct 3, 2023
$24,638
Ownership & Operations
Who Operates This Facility
Golden San Andreas Care Center
for profit
Chain Affiliation
Golden Snf Operations
7 facilities nationwide
Chain avg rating: 2.3/5 · Rank 7 of 7 (Worst)
Ownership & Management
Owners
Cafive Operations Holdings LLC
Owner · Organization
Ch Cafive Holdings LLC
Owner (parent company) · Organization
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
42 reviews from families & visitors
Medicare data downloads
Original nursing home datasets
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Safer Alternatives Nearby
Based on current clinical data, we identified 1 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.