All Saint's Subacute & Transitional Care
1652 Mono Avenue, San Leandro, CA 94578 · Alameda County · 86 certified beds · avg 63 residents/day · certified since Sep 9, 2004
Part of chain: PACS GROUP (274 facilities, chain avg rating 2.9★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.
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.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, facility-wide · Mar 25, 2025 · F-0880 · triggered by a complaint
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.
Why it matters: Weak infection control lets illnesses like flu, COVID-19, and drug-resistant infections spread quickly among vulnerable residents.
Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.
Corrected: Apr 15, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (23)
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 |
|---|---|---|
| Jun 23, 2026 | E · Potential for harm, repeated | 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. · from a complaint |
| Jun 23, 2026 | 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. · from a complaint |
| Jun 23, 2026 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Jun 23, 2026 | 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. · from a complaint |
| Feb 9, 2026 | 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 |
| Feb 9, 2026 | 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. · from a complaint |
| Mar 25, 2025 | ▲ L · Immediate jeopardy, facility-wide | 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. · from a complaint |
| Mar 25, 2025 | E · Potential for harm, repeated | 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. · from a complaint |
| Jul 12, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jul 12, 2024 | E · Potential for harm, repeated | 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. |
| Jul 12, 2024 | E · Potential for harm, repeated | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| Jul 12, 2024 | 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. |
| Jul 12, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jul 12, 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. |
| Jul 12, 2024 | D · Potential for harm, one-off | 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. |
| Jul 12, 2024 | D · Potential for harm, one-off | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. |
| Sep 29, 2023 | D · Potential for harm, one-off | The facility did not let a resident or their legal representative see or buy copies of the resident's own records. · from a complaint |
| Aug 3, 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. · from a complaint |
| May 19, 2022 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| May 19, 2022 | B · Minimal risk, repeated | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| May 19, 2022 | B · Minimal risk, repeated | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. |
| Nov 21, 2019 | 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. |
| Nov 21, 2019 | B · Minimal risk, repeated | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 2 | 0 | D |
| 2022 | 3 | 0 | D |
| 2023 | 2 | 0 | D |
| 2024 | 8 | 0 | E |
| 2025 | 2 | 1 | L ▲ |
| 2026 | 6 | 0 | E |
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)
2 fines totaling $163,127.
| Date | Type | Amount / length |
|---|---|---|
| Aug 22, 2025 | Fine | $30,933 |
| Mar 25, 2025 | Fine | $132,194 |
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) | 3.64 | 4.31 | 3.95 | bottom 17% in California; bottom 44% in the U.S. |
| Registered Nurse hours | 0.89 | 0.61 | 0.69 | top 14% in California; top 21% in the U.S. |
| Weekend total nurse staffing | 3.43 | 3.90 | 3.50 | bottom 25% in California; top 46% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 1.40 | 0.51 | 0.48 | top 4% in California; top 2% in the U.S. |
| Total nursing staff turnover (%) | 52.8 | 36.7 | 45.8 | bottom 10% in California; bottom 30% in the U.S. |
| RN turnover (%) | 69.2 | 38.1 | 42.9 | bottom 8% in California; bottom 12% 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 6.54, RN 1.61, weekend 6.17. Staffing rating: 3/5.
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: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Providence Group North LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 06/20/2016 |
| Apt, Frederick | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Hancock, Mark | Individual | Corporate Officer | NOT APPLICABLE | 02/10/2021 |
| Jergensen, Joshua | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Mitchell, John | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Muppu, Manjula | Individual | Contracted Managing Employee | NOT APPLICABLE | 01/01/2023 |
| Stock, Steven | Individual | W-2 Managing Employee | NOT APPLICABLE | 04/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "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 |
|---|---|---|---|---|---|
| All Saint's Maubert | 0.0 mi | San Leandro, CA | ★★☆☆☆ | 2/5 | |
| Alameda County Medical Center D/P SNF | 0.2 mi | San Leandro, CA | ★★★★★ | 5/5 | |
| Washington Center | 1.2 mi | San Leandro, CA | ★★★★★ | 5/5 | |
| Valley Pointe Nursing & Rehabilitation Center | 1.7 mi | Castro Valley, CA | ★★★★★ | 4/5 | |
| East Bay Post-Acute | 1.7 mi | Castro Valley, CA | ★★☆☆☆ | 1/5 | |
| San Leandro Healthcare Center | 2.1 mi | San Leandro, CA | ★★★★☆ | 4/5 | |
| Morton Bakar Center | 2.1 mi | Hayward, CA | ★★★★★ | 5/5 | |
| Bancroft Healthcare Center | 2.2 mi | San Leandro, CA | ★★★☆☆ | 4/5 | |
| Jones Convalescent Hospital | 2.3 mi | San Leandro, CA | ★★★★☆ | 4/5 | |
| Golden Harbor Healthcare Center | 2.4 mi | Hayward, CA | ★★☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 555809.