Facility Watch Inspection records for every certified US nursing home

Golden Sonora Care Center

19929 Greenley Road
Sonora, CA 95370
(209) 533-2500

CCN
555736
Certified beds
210
Ownership
For profit - Limited Liability company
Chain
Golden SNF Operations

Nurse staffing

4.65
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 0.38 hours per resident per day

Nursing staff turnover: 56% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected April 2, 2026

2 citations · from a complaint investigation · Health
D
F0770 No actual harm with potential for more than minimal harm · Isolated

Provide timely, quality laboratory services/tests to meet the needs of residents.

Deficient, Provider has no plan of correction
E
F0684 No actual harm with potential for more than minimal harm · Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has no plan of correction

Inspected March 12, 2026

1 citation · from a complaint investigation · Health
E
F0550 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected March 13, 2026

Inspected December 9, 2025

1 citation · from a complaint investigation · Health
D
F0757 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected December 10, 2025

Inspected September 2, 2025

1 citation · from a complaint investigation · Health
D
F0580 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected September 3, 2025

Inspected August 7, 2025

23 citations · from a complaint investigation · Health
D
F0550 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 8, 2025
D
F0554 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 8, 2025
D
F0580 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 8, 2025
D
F0585 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected August 8, 2025
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected August 8, 2025
D
F0657 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 8, 2025
D
F0658 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 8, 2025
D
F0688 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected August 8, 2025
D
F0689 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 8, 2025
D
F0690 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected August 8, 2025
D
F0759 No actual harm with potential for more than minimal harm · Isolated

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected August 8, 2025
D
F0814 No actual harm with potential for more than minimal harm · Isolated

Dispose of garbage and refuse properly.

Deficient, Provider has date of correction · corrected August 8, 2025
D
F0842 No actual harm with potential for more than minimal harm · Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Deficient, Provider has date of correction · corrected August 8, 2025
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected August 8, 2025
E
F0583 No actual harm with potential for more than minimal harm · Pattern

Keep residents' personal and medical records private and confidential.

Deficient, Provider has date of correction · corrected August 8, 2025
E
F0645 No actual harm with potential for more than minimal harm · Pattern

PASARR screening for Mental disorders or Intellectual Disabilities

Deficient, Provider has date of correction · corrected August 8, 2025
E
F0755 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected August 8, 2025
E
F0761 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected August 8, 2025
E
F0804 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected August 8, 2025
E
F0806 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected August 8, 2025
E
F0812 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected August 8, 2025
E
F0881 No actual harm with potential for more than minimal harm · Pattern

Implement a program that monitors antibiotic use.

Deficient, Provider has date of correction · corrected August 8, 2025
E
F0925 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected August 8, 2025

Inspected July 1, 2025

1 citation · from a complaint investigation · Health
D
F0689 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected July 1, 2025

Inspected June 11, 2025

1 citation · from a complaint investigation · Health
D
F0687 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate foot care.

Deficient, Provider has date of correction · corrected June 11, 2025

Inspected February 19, 2025

2 citations · from a complaint investigation · Health
D
F0655 No actual harm with potential for more than minimal harm · Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Deficient, Provider has date of correction · corrected February 19, 2025
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected February 19, 2025

Inspected January 29, 2025

1 citation · from a complaint investigation · Health
D
F0584 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected January 29, 2025

Inspected October 2, 2024

1 citation · from a complaint investigation · Health
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected October 8, 2024

Inspected July 23, 2024

1 citation · from a complaint investigation · Health
D
F0626 No actual harm with potential for more than minimal harm · Isolated

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Deficient, Provider has date of correction · corrected July 29, 2024

Inspected July 18, 2024

2 citations · from a complaint investigation · Health
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected July 29, 2024
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected July 29, 2024

Inspected June 20, 2024

15 citations · Health
D
F0550 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected June 20, 2024
D
F0558 No actual harm with potential for more than minimal harm · Isolated

Reasonably accommodate the needs and preferences of each resident.

Deficient, Provider has date of correction · corrected June 20, 2024
D
F0561 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Deficient, Provider has date of correction · corrected June 20, 2024
D
F0644 No actual harm with potential for more than minimal harm · Isolated

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Deficient, Provider has date of correction · corrected June 20, 2024
D
F0689 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected June 20, 2024
D
F0694 No actual harm with potential for more than minimal harm · Isolated

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Deficient, Provider has date of correction · corrected June 20, 2024
D
F0695 No actual harm with potential for more than minimal harm · Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Deficient, Provider has date of correction · corrected June 20, 2024
D
F0698 No actual harm with potential for more than minimal harm · Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Deficient, Provider has date of correction · corrected June 20, 2024
D
F0755 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected June 20, 2024
D
F0758 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected June 20, 2024
D
F0761 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected June 20, 2024
E
F0567 No actual harm with potential for more than minimal harm · Pattern

Honor the resident's right to manage his or her financial affairs.

Deficient, Provider has date of correction · corrected June 20, 2024
E
F0803 No actual harm with potential for more than minimal harm · Pattern

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Deficient, Provider has date of correction · corrected June 20, 2024
E
F0812 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected June 20, 2024
E
F0880 No actual harm with potential for more than minimal harm · Pattern

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected June 20, 2024

Inspected May 17, 2024

1 citation · from a complaint investigation · Health
D
F0636 No actual harm with potential for more than minimal harm · Isolated

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Deficient, Provider has date of correction · corrected May 23, 2024

Inspected April 11, 2024

1 citation · from a complaint investigation · Health
E
F0684 No actual harm with potential for more than minimal harm · Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected April 19, 2024

Inspected March 27, 2024

1 citation · from a complaint investigation · Health
E
F0880 No actual harm with potential for more than minimal harm · Pattern

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected April 17, 2024

Inspected March 5, 2024

1 citation · from a complaint investigation · Health
D
F0580 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected April 5, 2024

Inspected February 26, 2024

1 citation · from a complaint investigation · Health
G
F0689 Actual harm · Isolated

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

Deficient, Provider has date of correction · corrected March 18, 2024

Inspected January 9, 2024

2 citations · from a complaint investigation · Health
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected February 9, 2024
D
F0758 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected February 9, 2024

Inspected December 6, 2023

1 citation · from a complaint investigation · Health
D
F0658 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected January 3, 2024

Inspected October 20, 2023

1 citation · from a complaint investigation · Health
D
F0658 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected November 8, 2023

Inspected October 17, 2023

1 citation · from a complaint investigation · Health
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected October 20, 2023

Inspected October 11, 2023

1 citation · from a complaint investigation · Health
D
F0755 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected October 30, 2023

Inspected June 22, 2023

25 citations · Health
D
F0550 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected July 19, 2023
D
F0558 No actual harm with potential for more than minimal harm · Isolated

Reasonably accommodate the needs and preferences of each resident.

Deficient, Provider has date of correction · corrected July 19, 2023
D
F0568 No actual harm with potential for more than minimal harm · Isolated

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Deficient, Provider has date of correction · corrected July 19, 2023
D
F0584 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected July 19, 2023
D
F0655 No actual harm with potential for more than minimal harm · Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Deficient, Provider has date of correction · corrected July 19, 2023
D
F0658 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected July 19, 2023
D
F0679 No actual harm with potential for more than minimal harm · Isolated

Provide activities to meet all resident's needs.

Deficient, Provider has date of correction · corrected July 19, 2023
D
F0686 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected July 19, 2023
D
F0687 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate foot care.

Deficient, Provider has date of correction · corrected July 19, 2023
D
F0689 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected July 19, 2023
D
F0694 No actual harm with potential for more than minimal harm · Isolated

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Deficient, Provider has date of correction · corrected July 19, 2023
D
F0697 No actual harm with potential for more than minimal harm · Isolated

Provide safe, appropriate pain management for a resident who requires such services.

Deficient, Provider has date of correction · corrected July 19, 2023
D
F0759 No actual harm with potential for more than minimal harm · Isolated

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected July 19, 2023
D
F0761 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected July 19, 2023
D
F0806 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected July 19, 2023
E
F0656 No actual harm with potential for more than minimal harm · Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected July 19, 2023
E
F0677 No actual harm with potential for more than minimal harm · Pattern

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected July 19, 2023
E
F0684 No actual harm with potential for more than minimal harm · Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected July 19, 2023
E
F0695 No actual harm with potential for more than minimal harm · Pattern

Provide safe and appropriate respiratory care for a resident when needed.

Deficient, Provider has date of correction · corrected July 19, 2023
E
F0760 No actual harm with potential for more than minimal harm · Pattern

Ensure that residents are free from significant medication errors.

Deficient, Provider has date of correction · corrected July 19, 2023
E
F0804 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected July 19, 2023
E
F0842 No actual harm with potential for more than minimal harm · Pattern

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Deficient, Provider has date of correction · corrected July 19, 2023
E
F0880 No actual harm with potential for more than minimal harm · Pattern

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected July 19, 2023
F
F0812 No actual harm with potential for more than minimal harm · Widespread

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

Deficient, Provider has date of correction · corrected July 19, 2023
G
F0688 Actual harm · Isolated

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.

Deficient, Provider has date of correction · corrected July 19, 2023

Penalties

DateTypeAmount
February 26, 2024Fine$56,843
February 26, 2024Payment Denial · 21 days
June 22, 2023Fine$36,465

Ownership transfers

EffectiveSellerBuyer
03/01/2023Avalon Care Center-sonora, LLCSonora SNF Operations LLC

From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.