Your report for River City Post Acute
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- CaliforniaLowest tier among peers1,154 rated homes · average 3.2★
- Sacramento CountyLowest tier among peers36 rated homes · average 3.4★
- United StatesLowest tier among peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point1★−1.8 vs CA avg
- StaffingCan add or remove a star2★−1.1 vs CA avg
- Quality measuresCan add or remove a star3★−1.1 vs CA avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
- Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersCA avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover2★Above only 8% of peersCA avg3.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 9% of peersCA avg4.1★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.59hrsAbove only 3% of peersCA avg4.51Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.53hrsAbove 57% of peersCA avg0.65Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better54%Above only 10% of peersCA avg38%RN turnover79%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$0Above only 45% of peersCA avg$26,970Fines · denials0 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthFeb 2022 – Dec 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Dec 2, 2025Cycle 1worst D · no actual harm
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Dec 18, 2025
Nov 20, 2025Cycle 1worst D · no actual harm
- F551Give the resident's representative the ability to exercise the resident's rights.Resident RightsD · isolatedCorrected Dec 9, 2025
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Nov 24, 2025
Aug 7, 2025Cycle 1worst E · no actual harm
- F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalE · patternCorrected Aug 29, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Aug 29, 2025
Aug 1, 2025Cycle 1worst D · no actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 15, 2025
Jul 29, 2025Cycle 1worst D · no actual harm
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Aug 14, 2025
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Aug 14, 2025
- F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalD · isolatedCorrected Aug 14, 2025
Jul 24, 2025Cycle 1worst D · no actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 29, 2025
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Jul 29, 2025
Jul 1, 2025Cycle 1worst D · no actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jul 2, 2025
Jun 25, 2025Cycle 1worst D · no actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jun 26, 2025
Jun 11, 2025Cycle 1worst E · no actual harm
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jun 20, 2025
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Jun 20, 2025
Jun 6, 2025Cycle 1worst D · no actual harm
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Jun 13, 2025
Jun 3, 2025Cycle 1worst D · no actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 4, 2025
May 6, 2025Cycle 1worst D · no actual harm
- F559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.Resident RightsD · isolatedCorrected May 8, 2025
Apr 25, 2025Cycle 1worst D · no actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Apr 28, 2025
Apr 16, 2025Cycle 1worst D · no actual harm
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Apr 25, 2025
Apr 15, 2025Cycle 1worst E · no actual harm
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Apr 23, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Apr 23, 2025
Apr 3, 2025Cycle 1worst D · no actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Apr 21, 2025
Apr 2, 2025Cycle 1worst D · no actual harm
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Apr 14, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Apr 14, 2025
Feb 20, 2025Cycle 1worst D · no actual harm
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Mar 5, 2025
Nov 21, 2024Cycle 1worst E · no actual harm
- F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.EnvironmentalD · isolatedCorrected Dec 10, 2024
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Dec 10, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Dec 10, 2024
- F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesD · isolatedCorrected Dec 10, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryD · isolatedCorrected Dec 10, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Dec 10, 2024
- F908Keep all essential equipment working safely.EnvironmentalD · isolatedCorrected Dec 10, 2024
Oct 7, 2024Cycle 2worst D · no actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Oct 15, 2024
Sep 24, 2024Cycle 2worst F · no actual harm
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Oct 7, 2024
- F814Dispose of garbage and refuse properly.Nutrition and DietaryF · widespreadCorrected Oct 7, 2024
Aug 20, 2024Cycle 2worst D · no actual harm
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Sep 11, 2024
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Sep 11, 2024
- 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.Resident RightsD · isolatedCorrected Sep 11, 2024
Jul 19, 2024Cycle 2worst D · no actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 22, 2024
Jul 18, 2024Cycle 2worst E · no actual harm
- F685Assist a resident in gaining access to vision and hearing services.Quality of Life and CareE · patternCorrected Jul 18, 2024
Jul 2, 2024Cycle 2worst D · no actual harm
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryD · isolatedCorrected Jul 8, 2024
Jun 14, 2024Cycle 2worst E · no actual harm
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Jun 27, 2024
Jun 5, 2024Cycle 2worst D · no actual harm
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Jun 20, 2024
May 9, 2024Cycle 2worst E · no actual harm
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected May 10, 2024
- F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalD · isolatedCorrected May 10, 2024
Apr 29, 2024Cycle 2worst D · no actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 10, 2024
Apr 15, 2024Cycle 2worst D · no actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Apr 15, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Apr 15, 2024
Mar 11, 2024Cycle 2worst D · no actual harm
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Mar 27, 2024
Dec 14, 2023Cycle 2worst E · no actual harm
- F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.EnvironmentalE · patternCorrected Jan 9, 2024
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Jan 9, 2024
- 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.Resident RightsE · patternCorrected Jan 9, 2024
- F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Quality of Life and CareD · isolatedCorrected Jan 9, 2024
- F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Nutrition and DietaryE · patternCorrected Jan 9, 2024
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Jan 9, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Jan 9, 2024
Nov 7, 2023Cycle 3worst D · no actual harm
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Nov 28, 2023
Oct 20, 2023Cycle 3worst E · no actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Nov 7, 2023
Oct 4, 2023Cycle 3worst D · no actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Oct 18, 2023
Sep 18, 2023Cycle 3worst E · no actual harm
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrected Sep 29, 2023
Aug 9, 2023Cycle 3worst D · no actual harm
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Aug 25, 2023
Aug 1, 2023Cycle 3worst D · no actual harm
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Aug 12, 2023
Jul 10, 2023Cycle 3worst D · no actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jul 27, 2023
Jun 5, 2023Cycle 3worst D · no actual harm
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Jun 15, 2023
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Jun 15, 2023
May 24, 2023Cycle 3worst D · no actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 7, 2023
Apr 10, 2023Cycle 3worst D · no actual harm
- F660Plan the resident's discharge to meet the resident's goals and needs.Resident Assessment and Care PlanningD · isolatedCorrected May 2, 2023
Feb 21, 2023Cycle 3worst D · no actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 2, 2023
Feb 10, 2023Cycle 3worst E · no actual harm
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrected Mar 3, 2023
Feb 11, 2022Cycle 3worst F · no actual harm
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Mar 10, 2022
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Mar 10, 2022
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceE · patternCorrected Mar 10, 2022
- F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.EnvironmentalD · isolatedCorrected Mar 10, 2022
- F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident RightsD · isolatedCorrected Mar 10, 2022
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Mar 10, 2022
- F679Provide activities to meet all resident's needs.Quality of Life and CareD · isolatedCorrected Mar 10, 2022
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Mar 10, 2022
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Mar 10, 2022
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceE · patternCorrected Mar 10, 2022
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Mar 10, 2022
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Mar 10, 2022
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.59hrs
- Registered nursesRN hours only0.53hrs
- Licensed practical nursesLPN hours0.79hrs
- Nurse aidesCNA hours2.27hrs
- Weekend nursingAll staff on Saturdays and Sundays3.26hrs
- California average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better54%Above only 10% of peersCA avg 38%
- RN turnoverRegistered nurses only79%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy178 certified beds · ~172 residents a day97%Top 9%CA avg 88%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $0In fines
- 0Fines
- 0Payment denials
- $26,970CA avg in fines
Actions on record
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Corporation
- Chain
- Windsor18 facilities in the chain2.3★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Antelope Realty Holdings I, LLC
- Windsor Norcal 13 Holdings LLC
- 9560 Pico LLC
- Antelope Holdings I, LLC
- Pico Ar LLC
- Aaron Robin
- Avrohom Tress
- Newgen Administrative Services, LLC
- Ramsey Gardner
- Pamela Shaw
- Phonechia Thomas-Harrison
- Aaron Robin
- Avrohom Tress
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 055402 · 2540 CARMICHAEL WAY, CARMICHAEL, CA, 95608.
- Percentiles compare this facility with every rated nursing home in California and Sacramento County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









