Valley of the Moon Post Acute
347 Andrieux St, Sonoma, CA 95476 · Sonoma County · 27 certified beds · avg 26 residents/day · certified since Dec 19, 1986
Abuse citation flag (CMS)
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.
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 · Apr 15, 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: Apr 16, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 16, 2019 · F-0692
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
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 13, 2019 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 16, 2019 · F-0697
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
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 13, 2019 (Deficient, Provider has date of correction)
All citations in the current public record (29)
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 15, 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 |
| Oct 11, 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. |
| Oct 11, 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. |
| Oct 11, 2024 | E · Potential for harm, repeated | 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. |
| Oct 11, 2024 | 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. |
| Oct 11, 2024 | D · Potential for harm, one-off | 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. |
| Jul 28, 2023 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Jul 28, 2023 | 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. |
| Jul 28, 2023 | 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. |
| Jul 28, 2023 | 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. |
| Jul 28, 2023 | 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. |
| Oct 16, 2019 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Oct 16, 2019 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Oct 16, 2019 | F · Potential for harm, facility-wide | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Oct 16, 2019 | 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 16, 2019 | F · Potential for harm, facility-wide | 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. |
| Oct 16, 2019 | E · Potential for harm, repeated | 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 16, 2019 | 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. |
| Oct 16, 2019 | E · Potential for harm, repeated | 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. |
| Oct 16, 2019 | 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. |
| Oct 16, 2019 | 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. |
| Oct 16, 2019 | 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. |
| Oct 16, 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. |
| Oct 16, 2019 | 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. |
| Oct 16, 2019 | 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 16, 2019 | 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. |
| Oct 16, 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. |
| Oct 16, 2019 | D · Potential for harm, one-off | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Oct 16, 2019 | D · Potential for harm, one-off | The facility did not have policies on smoking. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (5 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 18 | 2 | G ▲ |
| 2023 | 5 | 0 | F |
| 2024 | 5 | 0 | E |
| 2026 | 1 | 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 $13,065.
| Date | Type | Amount / length |
|---|---|---|
| Apr 15, 2026 | Fine | $13,065 |
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) | 5.22 | 4.31 | 3.95 | top 11% in California; top 10% in the U.S. |
| Registered Nurse hours | 0.65 | 0.61 | 0.69 | top 28% in California; top 42% in the U.S. |
| Weekend total nurse staffing | 4.63 | 3.90 | 3.50 | top 11% in California; top 10% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.35 | 0.51 | 0.48 | bottom 46% in California; bottom 42% in the U.S. |
| Total nursing staff turnover (%) | 47.2 | 36.7 | 45.8 | bottom 20% in California; bottom 44% in the U.S. |
| RN turnover (%) | 66.7 | 38.1 | 42.9 | bottom 9% in California; bottom 15% 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 5.05, RN 0.63, weekend 4.48. 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: 5/5 · short-stay residents: 5/5
Who owns this facility
For profit - Individual
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Armfield, Benjamin | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2001 |
| Armfield, Benjamin | Individual | ADP of the SNF | NOT APPLICABLE | 04/01/2021 |
| Kaiser, Kelley | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/03/2025 |
| Kaiser, Kelley | Individual | ADP of the SNF | NOT APPLICABLE | 11/03/2025 |
| Okolo, Patrick | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/06/2025 |
| Okolo, Patrick | Individual | ADP of the SNF | NOT APPLICABLE | 10/06/2025 |
| Sonoma Valley Health Care District | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2007 |
| Sonoma Valley Health Care District | Organization | ADP of the SNF | NOT APPLICABLE | 05/21/2026 |
| Stone, Lisa | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2001 |
| Stone, Lisa | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2001 |
| Welch, Sherri | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/07/1992 |
| Welch, Sherri | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2007 |
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?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "Where do you post your latest state inspection results and the ombudsman's contact information?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "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 |
|---|---|---|---|---|---|
| Sonoma Post Acute | 0.6 mi | Sonoma, CA | ★★★★☆ | 3/5 | |
| Broadway Villa Post Acute | 0.9 mi | Sonoma, CA | ★★★★★ | 3/5 | |
| Vineyard Post Acute | 9.0 mi | Petaluma, CA | ★★★☆☆ | 2/5 | |
| The Meadows of Napa Valley | 9.3 mi | Napa, CA | ★★★★★ | 5/5 | |
| Napa Community Health Center | 9.4 mi | Napa, CA | ★☆☆☆☆ | 1/5 | |
| Veterans Home of California - Yountville - SNF | 9.4 mi | Yountville, CA | ★★★★★ | 4/5 | |
| Napa Valley Care Center | 10.0 mi | Napa, CA | ★★★☆☆ | 2/5 | |
| Napa Post Acute | 10.1 mi | Napa, CA | ★☆☆☆☆ | 1/5 | |
| North Bay Post Acute | 10.1 mi | Petaluma, CA | ★☆☆☆☆ | 1/5 | abuse |
| Hillcrest Post Acute | 10.8 mi | Petaluma, CA | ★★★★☆ | 4/5 | |
| Petaluma Post-Acute Rehabilitation | 10.8 mi | Petaluma, CA | ★★★★★ | 5/5 | |
| Ridgeway Post Acute | 10.8 mi | Petaluma, CA | ★☆☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 555258.