
Report
TheVardellReport
Santa Rosa Post Acute
Skilled nursing facility and nursing facility
4650 Hoen Avenue
Santa Rosa, CA 95405

TheVardellReport
Skilled nursing facility and nursing facility
4650 Hoen Avenue
Santa Rosa, CA 95405
Life by Vardell Presents
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Across 24 inspections from April 2021 to March 2026, state surveyors documented 50 findings at Santa Rosa Post Acute; 50 have a recorded correction; CMS lists 1 enforcement action in the window.
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2021 | 1 | 9 | 0 |
| 2022 | 0 | 0 | 0 |
| 2023 | 4 | 5 | 0 |
| 2024 | 8 | 12 | 0 |
| 2025 | 9 | 21 | 1 |
| 2026 | 2 | 3 | 0 |
Chronology
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.
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
10 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
4 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
No findings
Enforcement Action
Civil money penalty, $10,166 imposed January 28, 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 March 7, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
9 findings
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
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
Inspectors cited F755 in April 2021, December 2023, October 2024 and December 2025. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F880 in April 2021, December 2023, December 2024 and September 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. 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.
Inspectors cited F600 in January 2024, February 2026 and March 2026. This citation covers whether residents are protected from abuse and neglect by anyone. 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.
Inspectors cited F550 in April 2021 and December 2025. This citation covers residents’ right to dignity, to make their own choices and to communicate. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F576 in August 2024 and October 2024. The agency describes it this way: Ensure residents have reasonable access to and privacy in their use of communication methods. 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.
Inspectors cited F607 in April 2025 and May 2025. The agency describes it this way: Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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.
Inspectors cited F609 in April 2025 and April 2025. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. 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.
Inspectors cited F655 in April 2024 and September 2025. This citation covers the baseline care plan for a new resident’s immediate needs, due within 48 hours of admission. 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.
Inspectors cited F656 in April 2021 and January 2024. 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.
Inspectors cited F658 in November 2023 and September 2025. This citation covers whether the home’s services meet professional standards of quality. 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.
Inspectors cited F684 in December 2023 and September 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. 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.
For Your Next Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in four inspections, most seriously at level D.
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in four inspections, most seriously at level F.
What happened after the abuse or neglect citation, and what changed in training or supervision?
Protection From Abuse and Neglect: cited in three inspections, most seriously at level E.
How do staff learn each resident’s preferences, and how is a complaint about dignity handled?
Dignity and Resident Rights: cited in two inspections, most seriously at level D.
What changed after F576 was cited, and how do you check it now?
Citation F576: cited in two inspections, most seriously at level E.
What changed after F607 was cited, and how do you check it now?
Citation F607: cited in two inspections, most seriously at level F.
How are staff trained to report suspected abuse or neglect, and who reports it to the state?
Reporting Suspected Abuse: cited in two inspections, most seriously at level E.
What happens in the first 48 hours after admission, and who writes the first care plan?
The First 48 Hours: cited in two inspections, most seriously at level E.
How is a care plan written and reviewed here, and how do families take part in it?
Care Plans: cited in two inspections, most seriously at level E.
How do you check that nurses and aides follow professional standards, and what happens when they do not?
Professional Standards: cited in two inspections, most seriously at level E.
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in two inspections, most seriously at level E.
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.
What led to the 2025 fine, and has it been paid?
A $10,166 civil money penalty was imposed January 28, 2025. CMS publishes the fine, not whether it has been paid.
The Evidence
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the California state survey agency.
California state survey agency
Inspection Apr 23, 2021 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Nov 2, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Dec 14, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Dec 15, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Dec 22, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Jan 3, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Jan 24, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Mar 7, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Apr 10, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Aug 6, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Aug 28, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Oct 4, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Dec 5, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Jan 28, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Feb 24, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Mar 24, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Apr 9, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Apr 25, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection May 2, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Sep 2, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Sep 12, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Dec 26, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Feb 6, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Mar 11, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Centers for Medicare & Medicaid Services · 055854
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Record windowApril 23, 2021 – October 1, 2026
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.