Park View Post Acute
3751 Montgomery Dr, Santa Rosa, CA 95405 · Sonoma County · 116 certified beds · avg 106 residents/day · certified since Feb 1, 1975
Abuse citation flag (CMS)
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
2/5
Health inspection rating (on-site)
1
Serious findings on record
$9,347
Fines, last 3 years
4.40
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
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 · Jan 30, 2026 · F-0600 · triggered by a complaint
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.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
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: Dec 31, 2025 (Past Non-Compliance)
All citations in the current public record (43)
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 |
|---|---|---|
| Mar 5, 2026 | 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. |
| Mar 5, 2026 | F · Potential for harm, facility-wide | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Mar 5, 2026 | 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. |
| Mar 5, 2026 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Mar 5, 2026 | D · Potential for harm, one-off | 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. |
| Mar 5, 2026 | 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. |
| Mar 5, 2026 | 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. |
| Mar 5, 2026 | 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. |
| Jan 30, 2026 | ▲ G · Actual 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 3, 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. · from a complaint |
| Jul 17, 2025 | 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 2, 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. · from a complaint |
| Jun 2, 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 |
| Apr 29, 2025 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Jan 14, 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 |
| Jan 14, 2025 | 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 17, 2024 | 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. |
| May 17, 2024 | E · Potential for harm, repeated | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
| May 17, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| May 17, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| May 17, 2024 | E · Potential for harm, repeated | 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 17, 2024 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| May 17, 2024 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| May 17, 2024 | E · Potential for harm, repeated | The facility did not develop, carry out, or maintain an effective training program for all new and existing staff members. |
| May 17, 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 |
| May 17, 2024 | 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. · from a complaint |
| May 17, 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 |
| May 17, 2024 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| May 17, 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. |
| Nov 5, 2021 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Nov 5, 2021 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Nov 5, 2021 | 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. |
| Nov 5, 2021 | E · Potential for harm, repeated | The facility did not honor residents' individual preferences, choices, values, and beliefs in their daily life and care. |
| Nov 5, 2021 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Nov 5, 2021 | 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. |
| Nov 5, 2021 | E · Potential for harm, repeated | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Nov 5, 2021 | 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. |
| Nov 5, 2021 | 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. |
| Nov 5, 2021 | 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 5, 2021 | 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. |
| Nov 5, 2021 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Nov 5, 2021 | 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. |
| Nov 5, 2021 | D · Potential for harm, one-off | The facility did not provide each resident with a nourishing, tasty, well-balanced diet that meets their daily nutritional and special dietary needs. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (13 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 14 | 0 | E |
| 2024 | 13 | 0 | E |
| 2025 | 7 | 0 | E |
| 2026 | 9 | 1 | G ▲ |
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)
1 fine totaling $9,347.
| Date | Type | Amount / length |
|---|---|---|
| Jan 30, 2026 | Fine | $9,347 |
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) | 4.40 | 4.31 | 3.95 | top 33% in California; top 26% in the U.S. |
| Registered Nurse hours | 0.47 | 0.61 | 0.69 | bottom 48% in California; bottom 33% in the U.S. |
| Weekend total nurse staffing | 4.05 | 3.90 | 3.50 | top 31% in California; top 21% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.30 | 0.51 | 0.48 | bottom 34% in California; bottom 31% in the U.S. |
| Total nursing staff turnover (%) | 30.1 | 36.7 | 45.8 | top 29% in California; top 14% in the U.S. |
| RN turnover (%) | 44.0 | 38.1 | 42.9 | bottom 36% in California; bottom 46% 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 4.49, RN 0.48, weekend 4.13. 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: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Flagstone Healthcare North LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 01/30/2006 |
| The Ensign Group INC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 01/30/2006 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 02/01/2006 |
| Caretrust GP LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/01/2001 |
| Caretrust Reit INC | Organization | ADP of the SNF | NOT APPLICABLE | 04/01/2001 |
| CHG Medical Staffing, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2001 |
| CHG Medical Staffing, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 07/28/2025 |
| Ctr Partnership LP | Organization | ADP of the SNF | NOT APPLICABLE | 04/01/2001 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2002 |
| Jackson Therapy Partners LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2001 |
| Jackson Therapy Partners LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/28/2025 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Mountainview Communitycare LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/01/2001 |
| Port, Barry | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 07/16/2025 |
| Sae, Aynna | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/01/2025 |
| Sae, Aynna | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Sae, Aynna | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Willits, Adam | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/06/2014 |
| Willits, Adam | Individual | Corporate Officer | NOT APPLICABLE | 09/09/2024 |
| Willits, Adam | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/06/2014 |
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 did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What choices do residents have over their daily schedule, like meal times, bathing, and activities?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "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 |
|---|---|---|---|---|---|
| Summerfield Health Care Center | 0.8 mi | Santa Rosa, CA | ★★★★★ | 5/5 | |
| Santa Rosa Post Acute | 0.8 mi | Santa Rosa, CA | ★★★☆☆ | 2/5 | |
| Spring Lake Village | 1.6 mi | Santa Rosa, CA | ★★★★★ | 4/5 | |
| Blue Oak Post-Acute | 2.4 mi | Santa Rosa, CA | ★★☆☆☆ | 1/5 | abuse |
| Northvine Postacute Care | 3.5 mi | Santa Rosa, CA | ★☆☆☆☆ | 1/5 | |
| Arbol Healthcare Center of Santa Rosa | 3.6 mi | Santa Rosa, CA | ★★★★★ | 4/5 | |
| Apple Valley Post-Acute Rehab | 9.2 mi | Sebastopol, CA | ★★★★★ | 4/5 | |
| Vineyard Post Acute | 13.8 mi | Petaluma, CA | ★★★☆☆ | 2/5 | |
| North Bay Post Acute | 15.6 mi | Petaluma, CA | ★☆☆☆☆ | 1/5 | abuse |
| Valley of the Moon Post Acute | 15.7 mi | Sonoma, CA | ★★★☆☆ | 2/5 | abuse |
| Healdsburg Hospital D/P SNF | 15.8 mi | Healdsburg, CA | ★★★★☆ | 5/5 | |
| Hillcrest Post Acute | 15.9 mi | Petaluma, CA | ★★★★☆ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 056411.