Pacific Coast Manor
1935 Wharf Road, Capitola, CA 95010 · Santa Cruz County · 99 certified beds · avg 96 residents/day · certified since Apr 1, 1969
Part of chain: COVENANT CARE (12 facilities, chain avg rating 2.8★)
5/5
Health inspection rating (on-site)
0
Serious findings on record
$0
Fines, last 3 years
3.52
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★★5/5 · 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 (27)
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 |
|---|---|---|
| Apr 2, 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. · from a complaint |
| Feb 20, 2025 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Feb 20, 2025 | 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. |
| Aug 2, 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. · from a complaint |
| Aug 1, 2024 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. · from a complaint |
| May 9, 2024 | 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 13, 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 |
| Sep 11, 2023 | D · Potential for harm, one-off | The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. · from a complaint |
| Jun 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. |
| Jun 16, 2023 | 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 16, 2023 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Jun 16, 2023 | D · Potential for harm, one-off | 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. |
| Jun 16, 2023 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Jun 16, 2023 | 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. |
| Jun 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. |
| Jun 16, 2023 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Jun 16, 2023 | 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. |
| Jun 16, 2023 | D · Potential for harm, one-off | 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. |
| Jun 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. |
| Jun 16, 2023 | D · Potential for harm, one-off | The facility did not have a policy covering how food brought in by family and visitors is used and stored safely. |
| Jun 16, 2023 | D · Potential for harm, one-off | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. |
| Dec 5, 2019 | 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. |
| Dec 5, 2019 | 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. |
| Dec 5, 2019 | 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. |
| Dec 5, 2019 | 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. |
| Dec 5, 2019 | 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. |
| Dec 5, 2019 | D · Potential for harm, one-off | 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. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (13 → 2).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 6 | 0 | D |
| 2023 | 15 | 0 | E |
| 2024 | 3 | 0 | D |
| 2025 | 3 | 0 | 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) | 3.52 | 4.31 | 3.95 | bottom 11% in California; bottom 37% in the U.S. |
| Registered Nurse hours | 0.94 | 0.61 | 0.69 | top 13% in California; top 19% in the U.S. |
| Weekend total nurse staffing | 3.10 | 3.90 | 3.50 | bottom 7% in California; bottom 37% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 1.01 | 0.51 | 0.48 | top 7% in California; top 6% in the U.S. |
| Total nursing staff turnover (%) | 49.6 | 36.7 | 45.8 | bottom 15% in California; bottom 38% in the U.S. |
| RN turnover (%) | 63.3 | 38.1 | 42.9 | bottom 12% in California; bottom 17% 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 4.39, RN 1.17, weekend 3.88. 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: 4/5 · short-stay residents: 5/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Centre Capital Investors V, LP | Organization | 5% or Greater Indirect Ownership Interest | — | 07/17/2008 |
| Centre Covenant Purchaser (b), LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 07/17/2008 |
| Centre Covenant Purchaser (q), LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 07/17/2008 |
| Centre Covenant Purchaser (s), LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 12/19/2008 |
| Centre V Secondary Fund, L.P. | Organization | 5% or Greater Indirect Ownership Interest | — | 07/17/2008 |
| Covenant Care California, LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 06/01/2004 |
| Covenant Care, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 07/17/2008 |
| Covenant Holdco, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 07/17/2008 |
| Covenant Subco, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 07/17/2008 |
| Evans, Mary | Individual | 5% or Greater Indirect Ownership Interest | — | 07/17/2008 |
| Levin, Robert | Individual | 5% or Greater Indirect Ownership Interest | — | 07/17/2008 |
| Sims, Christine | Individual | 5% or Greater Indirect Ownership Interest | — | 07/17/2008 |
| State Treasurer of Mich Custodian of Public School Empl RTMNT Systems | Organization | 5% or Greater Indirect Ownership Interest | — | 12/19/2008 |
| Stockwell Fund II LP | Organization | 5% or Greater Indirect Ownership Interest | — | 12/19/2008 |
| Torok, Andrew | Individual | 5% or Greater Indirect Ownership Interest | — | 07/17/2008 |
| Ashley, Dava | Individual | Corporate Officer | NOT APPLICABLE | 05/07/2018 |
| Ashley, Dava | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/26/2018 |
| Carney, Kevin | Individual | Corporate Officer | NOT APPLICABLE | 11/01/2013 |
| Evans, Mary | Individual | Corporate Officer | NOT APPLICABLE | 11/01/2013 |
| Evans, Mary | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/17/2006 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "If you ever planned to discharge or transfer my family member, how much written notice would we receive and how could we appeal?"
- "How do you learn about each resident's background and history, and how does that shape their care?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Who provides social services here, and how would they support my family member's emotional and social needs?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "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 |
|---|---|---|---|---|---|
| Redwood Grove Post Acute | 1.3 mi | Santa Cruz, CA | ★★★☆☆ | 3/5 | |
| Driftwood Healthcare Center - Santa Cruz | 1.4 mi | Santa Cruz, CA | ★★★★☆ | 3/5 | |
| Santa Cruz Post Acute | 1.7 mi | Santa Cruz, CA | ★★☆☆☆ | 1/5 | |
| Watsonville Nursing Center | 11.2 mi | Watsonville, CA | ★★★☆☆ | 3/5 | |
| Watsonville Post Acute Center | 11.2 mi | Watsonville, CA | ★★★★★ | 4/5 | |
| Manresa Healthcare Center | 11.8 mi | Watsonville, CA | ★★★★☆ | 4/5 | |
| Vasona Creek Healthcare Center | 17.4 mi | Los Gatos, CA | ★★☆☆☆ | 3/5 | |
| The Terraces of Los Gatos | 17.8 mi | Los Gatos, CA | ★★★★★ | 5/5 | |
| Almaden Health and Rehabilitation Center | 18.4 mi | San Jose, CA | ★★★★☆ | 3/5 | |
| Stonebrook Health and Rehabilitation | 18.5 mi | Los Gatos, CA | ★★★★★ | 4/5 | |
| Woodlands Healthcare Center | 18.9 mi | Los Gatos, CA | ★★★★★ | 5/5 | |
| Plum Tree Care Center | 19.1 mi | San Jose, CA | ★★★★★ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 056048.