Report
TheVardellReport
All Saint's Maubert
Skilled nursing facility and nursing facility
15731 Maubert Avenue
San Leandro, CA 94578
Report
← All Saint's Maubert, free profile
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The Vardell Report.All Saint's Maubert
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- San Leandro, CA
- Record Period
- 2022–2026
- Source Documents
- 8
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 6 inspections from October 2022 to July 2026, state surveyors documented 30 findings at All Saint's Maubert; 30 have a recorded correction; CMS lists 1 enforcement action in the window.
- Inspections
- 6
- 2022–2026, complaint and standard
- Findings
- 30
- Deficiencies cited by state inspectors
- Corrected
- 30
- Of 30 findings, with a recorded correction date
- Penalties
- 1
- 1 fine; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2022 | 1 | 3 | 0 |
| 2023 | 1 | 12 | 0 |
| 2024 | 1 | 1 | 0 |
| 2025 | 2 | 11 | 1 |
| 2026 | 1 | 3 | 0 |
What the Record Shows
- 30 of 30 findings have a recorded correction date.
- CMS lists 1 enforcement action in the window: 1 fine of $131,856, its payment not published.
- 3 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, August 22, 2025, recorded 8 findings (most serious: Level F).
Report at a Glance
- Facility
- All Saint's Maubert
- Address
- 15731 Maubert Avenue, San Leandro, CA 94578
- CMS Certification Number
- 555879
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 14
- Ownership
- For profit - Limited Liability company
- Record Window
- October 13, 2022 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Complaint investigation
3 findings
- F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level FNo actual harm, potential for moreCorrected Aug 17, 2025
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level FNo actual harm, potential for moreCorrected Aug 13, 2026
- F839Employ staff that are licensed, certified, or registered in accordance with state laws.Level FNo actual harm, potential for moreCorrected Aug 17, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Standard health inspection
8 findings
- F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level FNo actual harm, potential for moreCorrected Dec 11, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Dec 11, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Dec 11, 2025
- F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level ENo actual harm, potential for moreCorrected Dec 11, 2025
- F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Dec 11, 2025
- F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level DNo actual harm, potential for moreCorrected Dec 11, 2025
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Dec 11, 2025
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Dec 11, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
3 findings
- F880Provide and implement an infection prevention and control program.Level LImmediate jeopardyCorrected Apr 14, 2025
- F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Level FNo actual harm, potential for moreCorrected Apr 14, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Apr 14, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Mar 5, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
12 findings
- F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Nov 23, 2023
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Nov 23, 2023
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level ENo actual harm, potential for moreCorrected Nov 23, 2023
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level ENo actual harm, potential for moreCorrected Nov 23, 2023
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Nov 23, 2023
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Nov 23, 2023
- F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Nov 23, 2023
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Nov 23, 2023
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Nov 23, 2023
- F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Nov 23, 2023
- F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Nov 23, 2023
- F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Level DNo actual harm, potential for moreCorrected Nov 23, 2023
Enforcement Action
Civil money penalty, $131,856 imposed March 25, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 26, 2023, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2022
Standard health inspection
3 findings
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level ENo actual harm, potential for moreCorrected Nov 15, 2022
- F732Post nurse staffing information every day.Level DNo actual harm, potential for moreCorrected Nov 15, 2022
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Nov 15, 2022
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Care Plans, Cited in Three Inspections
Inspectors cited F656 in October 2023, March 2025 and August 2025. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
222324252526F656 across all 6 inspections, oldest to newest - 2
Infection Control, Cited in Three Inspections
Inspectors cited F880 in October 2022, October 2023 and March 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. The most serious of these was recorded at level L (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
222324252526F880 across all 6 inspections, oldest to newest - 3
Pressure Injury Care, Cited in Two Inspections
Inspectors cited F686 in October 2022 and October 2023. This citation covers how the home prevents and treats pressure injuries (bedsores). None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
222324252526F686 across all 6 inspections, oldest to newest - 4
Citation F727, Cited in Two Inspections
Inspectors cited F727 in August 2025 and July 2026. The agency describes it this way: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
222324252526F727 across all 6 inspections, oldest to newest - 5
Medication Error Rate, Cited in Two Inspections
Inspectors cited F759 in October 2023 and August 2025. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
222324252526F759 across all 6 inspections, oldest to newest - 6
Kitchen and Food Safety, Cited in Two Inspections
Inspectors cited F812 in October 2023 and August 2025. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
222324252526F812 across all 6 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
How is a care plan written and reviewed here, and how do families take part in it?
Care Plans: cited in three inspections, most seriously at level E.
- 02
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in three inspections, most seriously at level L.
- 03
How often are residents checked for pressure injuries and repositioned, and who is responsible for it?
Pressure Injury Care: cited in two inspections, most seriously at level E.
- 04
What changed after F727 was cited, and how do you check it now?
Citation F727: cited in two inspections, most seriously at level F.
- 05
How are medication passes checked, and what happens when an error is found?
Medication Error Rate: cited in two inspections, most seriously at level E.
- 06
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in two inspections, most seriously at level F.
- 07
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 08
What led to the 2025 fine, and has it been paid?
A $131,856 civil money penalty was imposed March 25, 2025. CMS publishes the fine, not whether it has been paid.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the California state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Oct 13, 2022 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Oct 26, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Feb 5, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Mar 25, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Aug 22, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Jul 3, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 555879
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowOctober 13, 2022 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before October 2022 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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