San Luis Care Center
709 N Street, Newman, CA 95360 · Stanislaus County · 71 certified beds · avg 65 residents/day · certified since Aug 1, 1969
Part of chain: AVALON HEALTH CARE (16 facilities, chain avg rating 3.4★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
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 · Sep 12, 2025 · 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: Oct 3, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 30, 2024 · 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: Feb 29, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 30, 2024 · F-0656 · triggered by a complaint
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.
Why it matters: Without a complete, working care plan, important needs can slip through the cracks and no one is accountable for results.
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: Feb 29, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 28, 2019 · F-0655
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.
Why it matters: In the critical first days, staff may not know a new resident's medications, diet, or fall risks.
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: Jul 15, 2019 (Deficient, Provider has date of correction)
All citations in the current public record (42)
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 6, 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 6, 2026 | 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. |
| Mar 6, 2026 | E · Potential for harm, repeated | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| Mar 6, 2026 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Mar 6, 2026 | E · Potential for harm, repeated | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Mar 6, 2026 | 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. |
| Mar 6, 2026 | E · Potential for harm, repeated | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Mar 6, 2026 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Mar 6, 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 6, 2026 | 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. |
| Mar 6, 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 6, 2026 | 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 6, 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. |
| Mar 6, 2026 | 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. |
| Mar 6, 2026 | 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. |
| Mar 6, 2026 | D · Potential for harm, one-off | 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. |
| Sep 12, 2025 | ▲ 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 |
| Aug 8, 2024 | E · Potential for harm, repeated | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Aug 8, 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. |
| Aug 8, 2024 | 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. |
| Aug 8, 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. |
| Aug 8, 2024 | 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. |
| Aug 8, 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. |
| May 29, 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. · from a complaint |
| May 29, 2024 | 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 6, 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 |
| Jan 30, 2024 | ▲ 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 |
| Jan 30, 2024 | ▲ G · Actual 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 |
| Dec 19, 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. · from a complaint |
| Oct 4, 2023 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · from a complaint |
| May 28, 2019 | ▲ G · Actual 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. |
| May 28, 2019 | 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. |
| May 28, 2019 | 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. |
| May 28, 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. |
| May 28, 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. |
| May 28, 2019 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| May 28, 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. |
| May 28, 2019 | 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. |
| May 28, 2019 | 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. |
| May 28, 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. |
| May 28, 2019 | 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. |
| May 28, 2019 | 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. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (6 → 16).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 12 | 1 | G ▲ |
| 2023 | 2 | 0 | D |
| 2024 | 11 | 2 | G ▲ |
| 2025 | 1 | 1 | G ▲ |
| 2026 | 16 | 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)
1 fine totaling $46,118.
| Date | Type | Amount / length |
|---|---|---|
| Jan 30, 2024 | Fine | $46,118 |
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) | 3.96 | 4.31 | 3.95 | bottom 39% in California; top 41% in the U.S. |
| Registered Nurse hours | 0.40 | 0.61 | 0.69 | bottom 33% in California; bottom 23% in the U.S. |
| Weekend total nurse staffing | 3.63 | 3.90 | 3.50 | bottom 42% in California; top 36% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.23 | 0.51 | 0.48 | bottom 17% in California; bottom 18% in the U.S. |
| Total nursing staff turnover (%) | 37.5 | 36.7 | 45.8 | bottom 46% in California; top 30% in the U.S. |
| RN turnover (%) | 60.0 | 38.1 | 42.9 | bottom 16% in California; bottom 22% 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 3.85, RN 0.39, weekend 3.53. 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: 4/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Avalon Care LLC | Organization | 5% or Greater Indirect Ownership Interest | 100% | 09/09/2003 |
| Avalon Health Care INC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 12/01/2003 |
| Avalon of California LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 09/09/2003 |
| Avalon Health Care INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/01/2003 |
| Avalon Health Care INC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2003 |
| Avalon Health Care Management INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/01/2003 |
| Avalon Health Care Management INC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2003 |
| Borisevich, Maria | Individual | Corporate Officer | NOT APPLICABLE | 01/08/2024 |
| Borisevich, Maria | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/08/2024 |
| Borisevich, Maria | Individual | ADP of the SNF | NOT APPLICABLE | 01/08/2024 |
| Dangerfield, David | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/05/2007 |
| Dangerfield, David | Individual | Corporate Director | NOT APPLICABLE | 04/05/2007 |
| Deloitte Tax LLP | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2020 |
| Deloitte Tax LLP | Organization | ADP of the SNF | NOT APPLICABLE | 06/04/2025 |
| Eide Bailly LLP | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2021 |
| Eide Bailly LLP | Organization | ADP of the SNF | NOT APPLICABLE | 06/04/2025 |
| Hash, Alan | Individual | Corporate Officer | NOT APPLICABLE | 08/15/2017 |
| Hash, Alan | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2017 |
| Hash, Alan | Individual | ADP of the SNF | NOT APPLICABLE | 08/15/2017 |
| HHC Holdco LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/01/2021 |
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?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "How is your kitchen staffed, and have meals ever been delayed because of staffing?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "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 |
|---|---|---|---|---|---|
| Main West Postacute Care | 14.7 mi | Turlock, CA | ★★★☆☆ | 4/5 | |
| North Starr Postacute Care | 15.5 mi | Turlock, CA | ★★★★☆ | 4/5 | |
| Grace Home INC. | 16.3 mi | Livingston, CA | ★★★★★ | 5/5 | |
| Covenant Village Care Center | 16.4 mi | Turlock, CA | ★★★★☆ | 4/5 | |
| Turlock Nursing and Rehabilitation Center | 16.5 mi | Turlock, CA | ★★★☆☆ | 2/5 | |
| Ceres Postacute Care | 19.7 mi | Ceres, CA | ★★★☆☆ | 3/5 | |
| Los Banos Post Acute | 20.0 mi | Los Banos, CA | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 055839.