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Nursing HomeMedicaid Investigative

Golden Sonora Care Center

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

19929 Greenley Road, Sonora, CA 95370210 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
3.7/5

based on 79 Google reviews

5
4
3
2
1

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5/ 10
high Risk

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 (27 vs median 13.0)
  • High staff turnover (58%)
  • High RN turnover (54%)

Bottom 25% in CA · Critically understaffed (RN) · Worst in GOLDEN SNF OPERATIONS chain · $93,308 in fines

Source: Medicare data

What this means for your family

This facility is a strong candidate for families seeking a clean, well-lit environment with a generally compassionate nursing team. However, you should proactively ask about their protocols for responding to call lights and how they monitor the security of residents' personal belongings, as these have been significant pain points for others.

Google Reviews

Google Reviews

79 reviews on Google
Families considering Golden Sonora Care Center will find a facility with a highly praised, compassionate nursing and administrative staff, particularly in the memory care and rehab wings. However, there are significant, recurring reports of slow response times to call lights, inconsistent meal quality, and concerns regarding the security of personal belongings. While many recent reviews suggest the facility is improving under new administration, some families still report issues with staffing levels and communication regarding insurance and care plans.

Quality Themes

Tap a score for details
Food3.0Staff7.0Clean8.0ActivitiesN/AMedsN/AMemory6.0Comms4.0Value3.0

Strengths

  • Compassionate and friendly nursing staff
  • Clean and well-lit environment
  • Effective and helpful administration
  • Strong rehabilitation therapy services

Concerns

  • Slow response times to call lights (mentioned by 3 reviewers)
  • Inconsistent meal quality and timing (mentioned by 3 reviewers)
  • Issues with theft or loss of personal property (mentioned by 3 reviewers)
  • Staffing shortages or high turnover (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'14(3)'17(4)'19(3)'21(1)'23(5)'25(28)'26(7)

Distribution · 86 analyzed

5
50
4
11
3
4
2
1
1
20

How They Respond to Reviews

100%response rate
Generic

The owner relies heavily on repetitive templates and canned phrases. While they attempt to personalize some positive reviews by including the reviewer's name, the responses to negative reviews are almost entirely standardized scripts directing users to a phone number.

Questions for Your Tour

  • 1We noticed the administration is very active in responding to community feedback; how does the leadership team involve families in addressing concerns about meal timing or food quality?
  • 2With the focus on strong rehabilitation services, how do you coordinate therapy schedules to ensure residents are getting the most out of their sessions?
  • 3How does the nursing team manage call light response times during the night shifts to ensure residents feel supported?
  • 4What specific protocols are in place to ensure the security of residents' personal belongings and prevent any loss of property?
  • 5Could you tell us more about the daily activity calendar and how you keep residents engaged with the community?
  • 6In the event of a medical emergency after hours, what is the immediate process for notifying the family and coordinating care?

Personalized based on this facility's data


Key Review Excerpts

The clinical, administrative and support staff at Golden Sonora genuinely care for their residents. During my visits - I have seen hand first how much they care for their Community and find joy in caring for patient's that they have come to know as family.

Visitor · 2023★★★★★

The facility is well lit, clean, and organized. The staff are all super friendly, helpful and informative about anything you might have questions about.

Local Guide · 2024★★★★★

My father is receiving excellent care at Avalon. Each administrator we have come in contact with have been responsive to our inquiries and usually have followed up promptly with my father regarding his needs.

Long-term resident's family · 2024★★★★★
Source: 79 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.31hrs
42%
Registered nurses for medical care
Total Nursing
3.86hrs
94%
All nurses + aides combined
Staff Turnover
56%
Lower is better (< 30% = good)
RN Turnover
59%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
1/ 5
Better Than Avg

3

measures

Worse Than Avg

10

measures

Mixed Results

4

measures

Long-Stay Residents
🚶

Residents whose walking got worse

↓ Lower is better
This Facility31.6%
Worse than Avg
Here
31.6%
US
15.3%
CA
10.5%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility29.1%
Worse than Avg
Here
29.1%
US
14.4%
CA
10.4%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility26.8%
Worse than Avg
Here
26.8%
US
19.4%
CA
10.7%
😔

Residents with depression symptoms

↓ Lower is better
This Facility0.5%
Better than Avg
Here
0.5%
US
12.1%
CA
7.0%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility90.8%
Worse than Avg
Here
90.8%
US
93.4%
CA
98.6%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility20.2%
Worse than Avg
Here
20.2%
US
19.5%
CA
13.7%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility82.2%
Mixed vs Avgs
Here
82.2%
US
79.7%
CA
93.2%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility86.4%
Mixed vs Avgs
Here
86.4%
US
81.8%
CA
94.2%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility1.8%
Worse than Avg
Here
1.8%
US
1.6%
CA
1.5%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

28deficiencies
3penalties
Well above state avg (15.4)
31 complaint-triggered
$93,308 in fines

This facility shows serious concern with frequent family complaints triggering 29 deficiencies and persistent problems across medication management, care planning, and treatment quality. Families have repeatedly reported issues with notification of incidents, medication errors, and inadequate care. While most violations are eventually corrected, the pattern of recurring complaints about the same core care areas—particularly medication safety and proper treatment—suggests ongoing quality control problems that warrant careful consideration before placement.

Mar 12, 2026Complaint
1
0550Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Dec 9, 2025Complaint
1
0757Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Sep 2, 2025Complaint
1
0580Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Aug 7, 2025Routine
28
0583Potential for harm · PatternCorrected

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

0645Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

0755Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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.

0804Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

0806Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0881Potential for harm · PatternCorrected

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

0925Potential for harm · PatternCorrected

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0554Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

0585Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

0656Potential for harm · IsolatedCorrected

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.

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0688Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0814Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0161Potential for harm · IsolatedCorrected

Construction Deficiencies

Use approved construction type or materials.

0211Potential for harm · IsolatedCorrected

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0363Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0919Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the use of electrical equipment.

0920Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0341Minimal · WidespreadCorrected

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

Aug 7, 2025Complaint
2
0580Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

0842Potential for harm · IsolatedCorrected

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.

Jul 1, 2025Complaint
1
0689Potential for harm · IsolatedCorrected

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

Feb 26, 2024

$56,843

Payment Denial

Feb 26, 2024

21-day denial

Fine

Jun 22, 2023

$36,465

Ownership & Operations

Who Operates This Facility

Owner / Operator

Golden Sonora Care Center

Organization Type

for profit

Chain Affiliation

Chain Name

Golden Snf Operations

Chain Size

7 facilities nationwide

Chain avg rating: 2.3/5 · Rank 6 of 7 (Worst)

Ownership & Management

Owners

Sonora Operations Holdings LLC

Owner · Organization

100%

Ch Cafive Holdings LLC

Owner (parent company) · Organization

25%

Cw Cafive Holdings LLC

Owner (parent company) · Organization

25%

Key personnel

Barias, KarenManaging Control - Governing BodyEarl, StevenManaging Control - Governing BodySpielman, ShimonOfficer / DirectorYenowitz, YitzchokOfficer / DirectorCouve Healthcare Consulting LLCManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 2 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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