Home / California / Santa Rosa
5555 Montgomery Drive, Santa Rosa, CA 95409 · Sonoma County · (707) 538-8400
70 certified beds, about 42 residents a day · Non profit - Corporation · Medicare since 1986
CMS Care Compare ratings, data as of September 1, 2026 · CCN 555268 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on January 22, 2026, inspectors cited 4 health deficiencies (the California average is 15.6, the national average 9.2).
None of its 26 health citations since April 2023 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 5.54 hours per resident per day, against 4.52 across California and 3.86 nationally. Registered nurses accounted for 1.10 of those hours.
22.1% of nursing staff left within the year CMS measured (California average 36.7%).
CMS links it to Front Porch, an affiliated group of 9 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 26 health citations on file.
Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure, the enhanced barrier precautions (EBP, an infection control intervention, primarily used in nursing homes, that involve the use of gowns and gloves during high-contact resident care activities to reduce the transmission of infection) were implemented for two out of two residents sampled for infection control (Residents 29 and 45 ) that had opened wounds. This failure could result in increased transmission of germs and increased risk of infections among residents, staff, and visitors.
Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure one out of two residents sampled for restraints (Resident 46) was free from physical restraints that were not required to treat the resident's medical symptoms when:1. No medical symptom identified that required the use of a pommel cushion (a specialized wheelchair or chair cushion with a raised section (pommel) between the legs; can be considered a restraint requiring careful assessment and physician orders for safe use);2. No physician order for the use of the pommel cushion; and3. No ongoing monitoring and evaluation for Resident 46's use of the pommel cushion. These failures could put Resident 46 at risk for movement restrictions and reduced functional independence.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure two out of two residents sampled for grooming (Residents 29 and 16) received care to maintain grooming when their fingernails were long with brownish material underneath. This failure could negatively affect the residents' sense of dignity and be an infection control concern.
Inspectors wroteBased on observation, interviews and record reviews, the facility failed to preserve skin integrity for one out of two residents (Resident 29) sampled for pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) when pressure ulcer preventative measures were not consistently implemented for Resident 29. This failure resulted in Resident 29 developing a stage 2 pressure ulcer (Partial-thickness loss of skin, presenting as a shallow open sore or wound) on her coccyx (tailbone) while at the facility.
Inspectors wroteBased on interviews and record reviews, the facility failed to implement their policy to immediately report an allegation of abuse, for one resident out of three sampled residents (Resident 1), when Resident 1 notified staff of an allegation of abuse on 4/13/25 but was not reported to California Department of Public Health (the Department) until 4/15/245. This failure had the potential to leave Resident 1 vulnerable to further harm or abuse, delay the investigation and corrective actions to address the allegation of abuse.
Inspectors wrote1 b. During a review of Resident 14's face sheet (demographics), the face sheet indicated, Resident 14 was admitted to the facility on [DATE], with diagnoses which included sepsis (a life-threatening complication of an infection) and urinary tract infection (bladder infection). During a concurrent observation and interview on 2/9/25 at 4:06 p.m. with Resident 14, Resident 14 had an indwelling midline catheter (flexible tube inserted through the skin into a large vein in the arm used to administer IV antibiotics). There was no signage posted to alert staff that Resident 14 required Enhanced Barrier Precautions. Resident 14 stated that she was receiving Intravenous (IV) antibiotics (medicine that kills bacteria or stops their growth) for a urinary infection. During an observation on 2/10/25 at 4:10 p.m. [...]
Inspectors wroteBased on interview and record review, the facility failed to maintain an effective infection control training program related to Enhanced Barrier Precautions (EBP [Centers for Disease Control guidance to wear personal protective equipment when caring for residents with an indwelling medical device designed to reduce the spread of infections]). (cross reference to F880). This failure had the potential to negatively affect the facility's ability to maintain a safe environment to prevent the spread of infectious diseases among the 47 residents in the facility.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation guidelines were followed when: 1. Two kitchen staff did not wear hair nets while in the kitchen. 2. Five of five green cutting boards were not in good repair. 3. Dented cans were not discarded. 4. Six boxes of dry goods were stored directly on the floor. 5. Multiple food items were expired. 6. Multiple food items were unlabeled and undated. 7. Sanitizer for the vegetable wash was expired. These failures posed the risk for food borne illness in a medically fragile resident population of 47.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 18 sampled residents (Resident 29 and 37) needs and preferences were met when: 1. Resident 29's call light was not within reach. This failure had the potential to result in Resident 29 being unable to get assistance as needed. 2. Resident 37 did not recieve assistance to get out of bed and dressed earlier in the morning. This failure had the potential to adversely impact Resident 37's quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment when: 1. Personal use items including toothbrushes, toothpaste and combs were observed in a shared restroom for Residents 5, 8, 18, and 145 in a unlabeled wash basin (a pink colored wash basin/container for each resident used to store their personal use items). 2. Resident 18's personal use item was observed on Resident 145's (roommates) bedside table. These failures had the potential to cause illness and cross contamination in a medically compromised population.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the plan of care for two of 18 sampled residents (Resident 29 and Resident 22) when: 1. Resident 29 did not have bedside fall safety mats. 2. Resident 22's heels were not elevated off the bed. These failures had the potential to result in subsequent falls with serious injuries and worsening of skin breakdown.
Inspectors wroteBased on interview and record review, the facility failed to ensure weekly skin assessments were conducted and documented for one of 18 sampled residents (Resident 21) right heel pressure ulcer (PU- an injury to the skin caused by prolonged pressure on a specific area, often over bony prominences like the heels or tailbone). This failure had the potential to result in delayed treatment and servives required to promte wound healing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure shower disinfectant was stored in a locked storage container. This failure had the potential to result in unintentional access and harm.
Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively manage pain for one of 18 sampled residents (Resident 200). This failure resulted in unrelieved pain for Resident 200.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was not greater than five percent when five identified medication errors out of 41 opportunities for medication administration were observed: 1. Pradaxa (medication to treat irregular heart rate) was not administered with a full glass of water, as ordered, for one unsampled resident (Resident 14). 2. Furosemide (medication to treat high blood pressure) was given outside of dosing parameter instructions for one unsampled resident (Resident 14). 3. Aspirin (medication used to prevent stroke) was administered at the wrong time for one of 18 sampled residents (Resident 199). 4. Oxybutynin (medication used to treat overactive bladder) was administered at the wrong time for one of 18 sampled residents (Resident 199). 5. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure the daily maximum dosage of acetaminophen (medication used to treat pain) did not exceed 2,000 milligrams (mg- unit of measurement) per physician's order for one unsampled resident (Resident 36). This failure had the potential to result in hepatotoxicity (damage to the liver caused by exposure to harmful substances).
Inspectors wroteBased on observation, interview, and record review, the facility failed to store and label drugs and biologicals properly when: 1. Controlled drugs (drugs that are regulated by law due to their potential for abuse and addiction) were being discarded in a container that was not secure or permanently affixed to the wall. This failure had the potential to result in drug diversion (illegal distribution or abuse of prescription drugs.) 2. Resident 29's oxygen humidifier bottle was opened and undated. This failure had the potential to result in an increased risk for bacteria growth and progression of respiratory illness.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all kitchen staff were evaluated for competency skills when two kitchen staff were unable to effectively test the 3-compartment sink (3 sinks that separate the wash, rinse and sanitizer-manual procedure for cleaning and sanitizing dishes) sanitizer. This failure had the potential for residents to be served food on unclean dishes, which can result in food borne illnesses (a sickness caused by consuming food, or drinks contaminated with harmful substances) in a medically fragile population of 47 residents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all resident personal foods were labeled and dated in the communal refrigerator. This failure had the potential for residents to consume expired food that could lead to the increased risk of food borne illness (a sickness caused by consuming food contaminated with harmful substances).
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two outside dumpsters had a lid. This failure had the potential to attract pests and/or rodents that carried diseases and could result in food borne illness (a sickness caused by consuming food, or drinks contaminated with harmful substances) in a medically fragile population of 47 residents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the floors of the walk-in refrigerators and freezer were clean. This failure resulted in food storage areas that were not sanitary.
Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store its kitchen waste when the facility's recyling dumpster was propped open and had lids that did not properly close, and the trash compactor was left open. This failure could lead to infestation with insects or rodents.
Inspectors wroteBased on interview and record review, the facility failed to review and revise the care plans of two of 13 sampled residents (Residents 31 and 37) at least quarterly and as needed in order to ensure the needs of Residents 31 and 37 were met. For Resident 31, after the facility assessed Resident 31 to be at risk for pressure injuries (skin injuries caused by prolonged and unrelieved pressure), the facility failed to review and revise the pressure injury care plan at least quarterly and after Resident 31 developed pressure injuries. For Resident 37, after the facility assessed Resident 37 to be at high risk for falling, the facility failed to review and revise the fall prevention care plans after each fall and add different interventions when the fall prevention interventions in the care plan proved ineffective in preventing Resident 37 from falling. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to provide an activities program that supported the choice of activities of four of 13 sampled residents (Residents 17, 19, 35 and 38) when the facility did not have sufficient activities staff to take these residents out for fresh air and outdoor activities. This failure resulted in Residents 17, 19, 35 and 38 being deprived of fresh air and outdoor activities which they reported were very important to them.
Inspectors wroteBased on observation, interview, and record review, the facility staff failed to assess and document a large bruise on one of 13 sampled residents, Resident 12. This failure could potentially result in an unrecognized safety issue for the resident when the cause of the bruise was unknown.
Inspectors wroteBased on observation, interview and record review the facility failed to administer one medication to one Resident (Resident 26) per MD orders. This failure had the potential to cause Resident 26 to have dizziness, lightheadedness, drowsiness, and or a runny/stuffy nose.
34 fire safety citations on file: 6 on January 22, 2026, 10 on February 13, 2025, 18 on April 7, 2023.
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | California | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 5.54 | 4.52 | 3.86 |
| Registered nurses | 1.10 | 0.67 | 0.69 |
| All nursing staff on weekends | 4.85 | 4.09 | 3.42 |
| Nurse aides | 3.12 | ||
| Licensed practical nurses | 1.32 | ||
| Nursing staff turnover (share who left in a year) | 22.1% | 36.7% | 45.8% |
| Registered nurse turnover | 20.0% | 38.1% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.34 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 5.82 on weekdays and 4.85 on weekends, 17% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 1.5% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 5.35 in April to June 2025 to 5.54 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 5.54 | 1.10 | 5.82 | 4.85 | 1.5% | 0 of 90 | 42 |
| Oct to Dec 2025 | 5.09 | 1.09 | 5.37 | 4.36 | 0.6% | 0 of 92 | 45 |
| Jul to Sep 2025 | 5.22 | 1.12 | 5.48 | 4.58 | 1.8% | 0 of 92 | 45 |
| Apr to Jun 2025 | 5.35 | 0.96 | 5.65 | 4.60 | 0.7% | 0 of 91 | 45 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| California, Jan to Mar 2026 | 4.36 | 0.59 | 4.52 | 3.97 | 2.3% | 0.5% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| California, all employers | |||
| CNAs (nursing assistants) | $22.90 | $22.04 to $26.35 | 110,060 |
| LPNs and LVNs | $38.34 | $35.98 to $45.06 | 82,850 |
| Registered nurses | $67.44 | $58.87 to $83.25 | 338,940 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | California | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 15.4 | 10.3 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.8 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.2 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.4 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 26.8 | 9.8 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 2.6 | 4.3 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 10.5 | 12.0 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 19.2 | 22.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 9.7 | 11.2 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.9 | 2.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.4 | 1.6 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Spring Lake Village's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (64.2% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
64.2% this home
Better than the national rate
US median of homes 51.5% · California: 301 better, 190 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 177 eligible stays.
9.4% this home
No different from the national rate
US median of homes 10.7% · California: 10 better, 22 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 165 eligible stays.
6.2% this home
No different from the national rate
US median of homes 7.1% · California: 8 better, 48 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 105 eligible stays.
79.3% this home
Median of homes: California59.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 116 residents counted.
0.0% this home
Median of homes: California0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 131 residents counted.
1.6% this home
Median of homes: California0.6% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 131 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: California96.2% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 15 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: FRONT PORCH COMMUNITIES AND SERVICES. CMS links this home to Front Porch, a group of 9 nursing homes averaging 4.8 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Front Porch Communities and Services | 5% or greater direct ownership interest | Organization | 100% | 04/01/2022 |
| Duranteau, Nancy | Corporate director | Individual | 04/01/2021 | |
| Forte, Vincent | Corporate director | Individual | 04/01/2021 | |
| Handy, Joanne | Corporate director | Individual | 04/01/2021 | |
| Jacobs, Laura | Corporate director | Individual | 01/01/2019 | |
| Kroeker, Kevin | Corporate director | Individual | 01/01/2018 | |
| McGovern, Marion | Corporate director | Individual | 01/01/2017 | |
| Salvador, Eduardo | Corporate director | Individual | 10/03/2017 | |
| Spencer, Peter | Corporate director | Individual | 01/01/2026 | |
| Tonnu, Diemlan | Corporate director | Individual | 01/01/2018 | |
| Wesson, Oliver | Corporate director | Individual | 01/01/2017 | |
| Whittaker, Susan | Corporate director | Individual | 01/23/2018 | |
| Kelly, Sean | Corporate officer | Individual | 03/06/2023 | |
| Vranich, Rachel | Corporate officer | Individual | 06/17/2022 | |
| Akopyan, Gevork | Operational/managerial control | Individual | 10/12/2022 | |
| Bout, Ferdinand | Operational/managerial control | Individual | 12/29/2025 | |
| Ichien, Christopher | Operational/managerial control | Individual | 06/04/2018 | |
| Jumawan, Kristyl | Operational/managerial control | Individual | 01/20/2026 | |
| Kelly, Sean | Operational/managerial control | Individual | 03/06/2023 | |
| Macango, Susan | Operational/managerial control | Individual | 05/04/2026 | |
| McMullin, Mary | Operational/managerial control | Individual | 04/01/2025 | |
| Olson, Kari | Operational/managerial control | Individual | 04/01/2021 | |
| Salvador, Eduardo | Operational/managerial control | Individual | 04/01/2021 | |
| Skillman, Daniel | Operational/managerial control | Individual | 04/05/2021 | |
| Zelk, Misty | Operational/managerial control | Individual | 07/05/2022 | |
| Front Porch Communities and Services | Adp of the SNF | Organization | 04/01/2022 | |
| Skillman, Daniel | Adp of the SNF | Individual | 04/05/2021 | |
| Zelk, Misty | Adp of the SNF | Individual | 05/01/2026 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in California. NursingHomeClear cannot take or act on complaints.