Adventist Health Sonora - D/P SNF

Name: Adventist Health Sonora - D/P SNF
Address: 179 SOUTH FAIRVIEW LANE, Sonora, CA, 95370, US
Telephone: 2095363779

179 South Fairview Lane, Sonora, CA 95370 · Tuolumne County · 68 certified beds · avg 63 residents/day · certified since Oct 7, 1985

Part of chain: ADVENTIST HEALTH (5 facilities, chain avg rating 4.0★)

4/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

5.26

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★☆4/5 · CMS overall rating: 5/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (39)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jan 23, 2026	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Jun 19, 2025	E · Potential for harm, repeated	The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function.
Jun 19, 2025	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jun 19, 2025	E · Potential for harm, repeated	The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Jun 19, 2025	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jun 19, 2025	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
May 20, 2025	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
May 9, 2024	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
May 9, 2024	E · Potential for harm, repeated	The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
May 9, 2024	E · Potential for harm, repeated	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
May 9, 2024	E · Potential for harm, repeated	The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
May 9, 2024	E · Potential for harm, repeated	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
May 9, 2024	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
May 9, 2024	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
May 9, 2024	D · Potential for harm, one-off	The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal.
May 9, 2024	D · Potential for harm, one-off	The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids.
May 9, 2024	D · Potential for harm, one-off	The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
May 9, 2024	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
May 9, 2024	D · Potential for harm, one-off	The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them.
May 9, 2024	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Mar 21, 2024	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Feb 20, 2024	D · Potential for harm, one-off	The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint
Dec 15, 2023	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Dec 15, 2023	D · Potential for harm, one-off	The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Mar 16, 2023	E · Potential for harm, repeated	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Mar 16, 2023	E · Potential for harm, repeated	The facility did not honor residents' right to manage their own money and financial affairs.
Mar 16, 2023	E · Potential for harm, repeated	The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Mar 16, 2023	E · Potential for harm, repeated	The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Mar 16, 2023	E · Potential for harm, repeated	The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.
Mar 16, 2023	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Mar 16, 2023	D · Potential for harm, one-off	The facility did not properly hold, secure, and manage residents' personal money that was deposited with it for safekeeping. Facilities holding residents' funds must keep careful, honest accounts.
Mar 16, 2023	D · Potential for harm, one-off	The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered.
Mar 16, 2023	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Mar 16, 2023	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Mar 16, 2023	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Mar 16, 2023	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Mar 16, 2023	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Mar 16, 2023	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Mar 16, 2023	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (13 → 5).

Year	Citations	Worst severity that year
2023	17	E
2024	15	F
2025	6	E
2026	1	D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	California avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	5.26	4.31	3.95	top 11% in California; top 10% in the U.S.
Registered Nurse hours	1.23	0.61	0.69	top 6% in California; top 9% in the U.S.
Weekend total nurse staffing	4.47	3.90	3.50	top 15% in California; top 12% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.75	0.51	0.48	top 13% in California; top 13% in the U.S.
Total nursing staff turnover (%)	28.4	36.7	45.8	top 25% in California; top 12% in the U.S.
RN turnover (%)	22.7	38.1	42.9	top 24% in California; top 18% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.71, RN 1.11, weekend 4.01. Staffing rating: 5/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: —/5

Who owns this facility

Non profit - Church related

Owner / manager	Type	Role	Stake	Since
Adventist Health System/West	Organization	Operational/Managerial Control	NOT APPLICABLE	06/16/1980
Freedman, John	Individual	Corporate Director	NOT APPLICABLE	09/26/2016
Gabriel, Melody	Individual	Corporate Director	NOT APPLICABLE	06/01/2015
Graham, Ricardo	Individual	Corporate Director	NOT APPLICABLE	06/01/2015
Heinrich, Kerry	Individual	Corporate Director	NOT APPLICABLE	12/16/2014
Innocent, Larry	Individual	Corporate Director	NOT APPLICABLE	06/01/2015
Jahn, Andrew	Individual	W-2 Managing Employee	NOT APPLICABLE	08/08/2011
Jahn, Andrew	Individual	Corporate Officer	NOT APPLICABLE	02/03/2014
Jobe, Meredith	Individual	Corporate Officer	NOT APPLICABLE	03/31/2014
McCulloch, Gregory	Individual	Contracted Managing Employee	NOT APPLICABLE	05/05/2014
McCulloch, Gregory	Individual	W-2 Managing Employee	NOT APPLICABLE	05/05/2014
McCulloch, Gregory	Individual	Corporate Officer	NOT APPLICABLE	05/05/2014
Pedersen, James	Individual	Corporate Director	NOT APPLICABLE	01/16/2017
Reiner, Brian	Individual	Corporate Director	NOT APPLICABLE	05/13/2011
Reiner, Brian	Individual	Corporate Officer	NOT APPLICABLE	03/14/2014
Reiner, Richard	Individual	Corporate Director	NOT APPLICABLE	01/16/2017
Rippey, Wesley	Individual	Corporate Director	NOT APPLICABLE	06/01/2015
Salazar, Velino	Individual	Corporate Director	NOT APPLICABLE	09/15/2015
Wagner, Jack	Individual	Corporate Officer	NOT APPLICABLE	03/31/2014
Wing, Billy	Individual	Corporate Director	NOT APPLICABLE	03/31/2014

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
"What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"How does your quality committee work, and can you give an example of a problem it recently identified and fixed?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
"Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
"What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Golden Sonora Care Center	1.1 mi	Sonora, CA	★☆☆☆☆	1/5

Compare this facility with the 1 closest →

All facilities in Sonora →

Facility data as of CMS processing date 2026-08-01. CCN 555209.

The Care File

Visit checklist — Adventist Health Sonora - D/P SNF

179 South Fairview Lane, Sonora, CA 95370 · 2095363779

Health inspection rating 4/5 · CMS overall 5/5· Fines (3y): $0

Questions for the administrator:

☐ "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
☐ "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "How does your quality committee work, and can you give an example of a problem it recently identified and fixed?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
☐ "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
☐ "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 555209 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)