Devonshire Oaks Nursing Center

Name: Devonshire Oaks Nursing Center
Address: 3635 JEFFERSON AVENUE, Redwood City, CA, 94062, US
Telephone: 6503669503

3635 Jefferson Avenue, Redwood City, CA 94062 · San Mateo County · 38 certified beds · avg 32 residents/day · certified since Nov 8, 2004

4/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

5.69

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.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Aug 1, 2023 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Sep 1, 2023 (Deficient, Provider has date of correction)

All citations in the current public record (28)

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 17, 2025	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.
Jan 17, 2025	D · Potential for harm, one-off	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.
Jan 17, 2025	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.
Jan 17, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jan 17, 2025	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Jan 17, 2025	D · Potential for harm, one-off	The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life.
Oct 27, 2023	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.
Oct 27, 2023	E · Potential for harm, repeated	When a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care.
Oct 27, 2023	E · Potential for harm, repeated	The facility did not have enough support staff to safely and effectively run its food and nutrition service.
Oct 27, 2023	E · Potential for harm, repeated	The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.
Oct 27, 2023	E · Potential for harm, repeated	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Oct 27, 2023	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.
Oct 27, 2023	D · Potential for harm, one-off	The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings.
Oct 27, 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.
Oct 27, 2023	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.
Oct 27, 2023	D · Potential for harm, one-off	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.
Oct 27, 2023	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Oct 27, 2023	D · Potential for harm, one-off	The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day.
Oct 27, 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.
Oct 27, 2023	D · Potential for harm, one-off	The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service.
Oct 27, 2023	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. · from a complaint
Aug 1, 2023	▲ G · Actual 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
Nov 10, 2021	F · Potential for harm, facility-wide	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Nov 10, 2021	F · Potential for harm, facility-wide	The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Nov 10, 2021	E · Potential for harm, repeated	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Nov 10, 2021	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.
Nov 10, 2021	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.
Nov 10, 2021	D · Potential for harm, one-off	The facility did not have enough support staff to safely and effectively run its food and nutrition service.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (14 → 6).

Year	Citations	Serious (G–L)	Worst severity that year
2021	6	0	F
2023	16	1	G ▲
2025	6	0	F

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)	5.69	4.31	3.95	top 6% in California; top 6% in the U.S.
Registered Nurse hours	1.68	0.61	0.69	top 3% in California; top 3% in the U.S.
Weekend total nurse staffing	4.79	3.90	3.50	top 9% in California; top 8% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.69	0.51	0.48	top 16% in California; top 17% in the U.S.
Total nursing staff turnover (%)	0.0	36.7	45.8	—
RN turnover (%)	0.0	38.1	42.9	—

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 4.64, RN 1.37, weekend 3.91. Staffing rating: 4/5.

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: 4/5 · short-stay residents: 5/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Cabanayan, Danilo	Individual	5% or Greater Direct Ownership Interest	50%	11/01/2003
Cabanayan, Loreta	Individual	5% or Greater Direct Ownership Interest	50%	07/01/2003
St. Therese Convalescent Hospital ,INC.	Organization	5% or Greater Direct Ownership Interest	—	07/01/2003
Cabanayan, Danilo	Individual	W-2 Managing Employee	NOT APPLICABLE	07/01/2003
Cabanayan, Danilo	Individual	Corporate Officer	NOT APPLICABLE	11/01/2003
Cabanayan, Danilo	Individual	Operational/Managerial Control	NOT APPLICABLE	09/01/2021
Cabanayan, Danilo	Individual	General Partnership Interest	NOT APPLICABLE	11/01/2003

Questions to ask on your visit

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

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
"Can you show me an example care plan, and how are families included when it's created and updated?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
"How do you coordinate hospice care, and can residents stay here while receiving it?"
"What exactly do you hand off to the next provider when a resident is discharged, and how do you confirm they received 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
Atherton Park Post-Acute	3.4 mi	Menlo Park, CA	★★★★☆	3/5
Belmont Healthcare Center	3.8 mi	Belmont, CA	★★★★★	5/5
VI at Palo Alto	4.2 mi	Palo Alto, CA	★★★★★	4/5
Webster House	5.0 mi	Palo Alto, CA	★★★★★	5/5
Palo Alto Post-Acute	5.2 mi	Palo Alto, CA	★★★★☆	3/5
San Mateo Medical Center D/P SNF	5.3 mi	San Mateo, CA	★☆☆☆☆	1/5
Brookside Skilled Nursing Hospital	6.3 mi	San Mateo, CA	★★★★★	4/5
The Sequoias	6.4 mi	Portola Valley, CA	★★★★★	5/5
The Terraces at Los Altos Health Facility	8.7 mi	Los Altos, CA	★★★★☆	3/5
Villa Siena	10.8 mi	Mountain View, CA	★☆☆☆☆	3/5
Camino Ridge Post-Acute	11.3 mi	Mountain View, CA	★☆☆☆☆	1/5
Peninsula Post-Acute	11.4 mi	Burlingame, CA	★★★★☆	4/5

Compare this facility with the 3 closest →

All facilities in Redwood City →

Facility data as of CMS processing date 2026-08-01. CCN 555813.

The Care File

Visit checklist — Devonshire Oaks Nursing Center

3635 Jefferson Avenue, Redwood City, CA 94062 · 6503669503

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

Most serious findings on record:

▲ Aug 1, 2023 (F-0689, Actual 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.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
☐ "How do you coordinate hospice care, and can residents stay here while receiving it?"
☐ "What exactly do you hand off to the next provider when a resident is discharged, and how do you confirm they received 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 555813 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)