Sonoma Post Acute

Name: Sonoma Post Acute
Address: 678 2ND STREET WEST, Sonoma, CA, 95476, US
Telephone: 7079381096

678 2nd Street West, Sonoma, CA 95476 · Sonoma County · 83 certified beds · avg 79 residents/day · certified since Jan 1, 1967

Part of chain: PACS GROUP (274 facilities, chain avg rating 2.9★)

3/5

Health inspection rating (on-site)

Serious findings on record

$18,470

Fines, last 3 years

3.73

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5

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)

▲ Immediate jeopardy, facility-wide · Mar 30, 2022 · F-0695

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.

Why it matters: Mistakes in breathing care can quickly become life-threatening for residents who depend on oxygen or equipment.

Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.

Corrected: Apr 24, 2022 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Apr 22, 2026 · 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: May 13, 2026 (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
Jun 25, 2026	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
Jun 25, 2026	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Apr 22, 2026	▲ 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
Apr 16, 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.
Apr 16, 2026	F · Potential for harm, facility-wide	The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
Apr 16, 2026	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.
Apr 16, 2026	E · Potential for harm, repeated	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.
Apr 16, 2026	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.
Apr 16, 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.
Apr 16, 2026	D · Potential for harm, one-off	The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids.
Apr 16, 2026	D · Potential for harm, one-off	The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care.
Apr 16, 2026	D · Potential for harm, one-off	The facility did not have enough support staff to safely and effectively run its food and nutrition service.
Apr 16, 2026	D · Potential for harm, one-off	The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.
Nov 14, 2025	D · Potential for harm, one-off	The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint
Aug 1, 2025	D · Potential for harm, one-off	The facility hired someone with an official finding of abuse, neglect, exploitation, or theft against them. Facilities are not allowed to employ people with such findings. · from a complaint
Aug 1, 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
Jul 22, 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
Jul 18, 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
May 16, 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
Mar 20, 2025	D · Potential for harm, one-off	The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. · from a complaint
Jan 30, 2025	E · Potential for harm, repeated	The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. · from a complaint
Jun 13, 2024	D · Potential for harm, one-off	The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint
Mar 30, 2022	▲ L · Immediate jeopardy, facility-wide	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.
Mar 30, 2022	F · Potential for harm, facility-wide	The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Mar 30, 2022	F · Potential for harm, facility-wide	The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service.
Mar 30, 2022	F · Potential for harm, facility-wide	The facility did not have enough support staff to safely and effectively run its food and nutrition service.
Mar 30, 2022	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.
Mar 30, 2022	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.
Mar 30, 2022	E · Potential for harm, repeated	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Mar 30, 2022	E · Potential for harm, repeated	The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
Mar 30, 2022	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.
Mar 30, 2022	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.
Mar 30, 2022	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.
Mar 30, 2022	E · Potential for harm, repeated	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Mar 30, 2022	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.
Mar 30, 2022	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.
Mar 30, 2022	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 30, 2022	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 30, 2022	E · Potential for harm, repeated	The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives.
Mar 30, 2022	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.
Mar 30, 2022	D · Potential for harm, one-off	The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services.
Mar 30, 2022	D · Potential for harm, one-off	The facility did not provide special eating equipment and utensils — like adaptive cups or easy-grip silverware — for residents who need them, along with appropriate help at meals.

Inspection trend by year

Year	Citations	Serious (G–L)	Worst severity that year
2022	20	1	L ▲
2024	1	0	D
2025	8	0	E
2026	13	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 $18,470.

Date	Type	Amount / length
Apr 16, 2026	Fine	$18,470

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)	3.73	4.31	3.95	bottom 22% in California; bottom 48% in the U.S.
Registered Nurse hours	0.64	0.61	0.69	top 29% in California; top 43% in the U.S.
Weekend total nurse staffing	3.03	3.90	3.50	bottom 5% in California; bottom 33% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.33	0.51	0.48	bottom 41% in California; bottom 38% in the U.S.
Total nursing staff turnover (%)	42.7	36.7	45.8	bottom 31% in California; top 44% in the U.S.
RN turnover (%)	46.7	38.1	42.9	bottom 32% in California; bottom 41% 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 3.58, RN 0.62, weekend 2.91. 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
Providence Group NH, LLC	Organization	5% or Greater Indirect Ownership Interest	100%	06/30/2023
Providence Group Wine Country LLC	Organization	5% or Greater Direct Ownership Interest	100%	12/16/2016
Apt, Frederick	Individual	Corporate Officer	NOT APPLICABLE	01/01/2024
Hancock, Mark	Individual	Corporate Officer	NOT APPLICABLE	01/01/2024
Jergensen, Joshua	Individual	Corporate Officer	NOT APPLICABLE	01/01/2024
Mitchell, John	Individual	Corporate Officer	NOT APPLICABLE	01/01/2024
Olson, Jon	Individual	W-2 Managing Employee	NOT APPLICABLE	11/05/2021
Olson, Jon	Individual	Operational/Managerial Control	NOT APPLICABLE	11/05/2021
Picetti, Dominic	Individual	Contracted Managing Employee	NOT APPLICABLE	03/01/2024

Questions to ask on your visit

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

"How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
"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?"
"When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"How do you inspect and maintain essential equipment, and how quickly are repairs made?"
"Where do you post your latest state inspection results and the ombudsman's contact information?"
"How do you learn about each resident's background and history, and how does that shape their care?"
"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
Valley of the Moon Post Acute	0.6 mi	Sonoma, CA	★★★☆☆	2/5	abuse
Broadway Villa Post Acute	0.8 mi	Sonoma, CA	★★★★★	3/5
The Meadows of Napa Valley	8.7 mi	Napa, CA	★★★★★	5/5
Napa Community Health Center	8.8 mi	Napa, CA	★☆☆☆☆	1/5
Veterans Home of California - Yountville - SNF	9.1 mi	Yountville, CA	★★★★★	4/5
Napa Valley Care Center	9.5 mi	Napa, CA	★★★☆☆	2/5
Vineyard Post Acute	9.5 mi	Petaluma, CA	★★★☆☆	2/5
Napa Post Acute	9.5 mi	Napa, CA	★☆☆☆☆	1/5
Dept of State Hospitals - Napa D/P SNF	10.4 mi	Napa, CA	★★★☆☆	2/5
North Bay Post Acute	10.6 mi	Petaluma, CA	★☆☆☆☆	1/5	abuse
Hillcrest Post Acute	11.3 mi	Petaluma, CA	★★★★☆	4/5
Petaluma Post-Acute Rehabilitation	11.3 mi	Petaluma, CA	★★★★★	5/5

Compare this facility with the 3 closest →

All facilities in Sonoma →

Facility data as of CMS processing date 2026-08-01. CCN 055268.

The Care File

Visit checklist — Sonoma Post Acute

678 2nd Street West, Sonoma, CA 95476 · 7079381096

Health inspection rating 3/5 · CMS overall 4/5· Fines (3y): $18,470

Most serious findings on record:

▲ Mar 30, 2022 (F-0695, Immediate jeopardy, facility-wide): 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.
▲ Apr 22, 2026 (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:

☐ "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
☐ "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?"
☐ "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "How do you inspect and maintain essential equipment, and how quickly are repairs made?"
☐ "Where do you post your latest state inspection results and the ombudsman's contact information?"
☐ "How do you learn about each resident's background and history, and how does that shape their care?"
☐ "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 055268 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)