Overall Score
CMS Five-Star Quality RatingMuch above averageCMS Five-Star overall rating
- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- CaliforniaAbove 76% of peers1,154 rated homes · average 3.2★
- United StatesAbove 80% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point4★+1.2 vs CA avg
- StaffingCan add or remove a star4★+0.9 vs CA avg
- Quality measuresCan add or remove a star5★+0.9 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.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles4★Above 66% of peersCA avg2.8★U.S. avg2.8★
What is health inspection rating?
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.
Why it matters
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 turnover4★Above 60% of peersCA avg3.1★U.S. avg2.9★
What is staffing rating?
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.
Why it matters
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 assessments5★Above 57% of peersCA avg4.1★U.S. avg3.6★
What is quality measures rating?
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.
Why it matters
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 staff3.99hrsAbove only 23% of peersCA avg4.51Benchmark4.10
What is total nurse hours?
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Why it matters
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 only0.44hrsAbove only 41% of peersCA avg0.65Benchmark0.75
What is rn hours?
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
Why it matters
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 better25%Above 85% of peersCA avg38%RN turnover—
What is nursing staff turnover?
The share of nursing staff who left within the past year, from the same payroll data.
Why it matters
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$12,545Above only 33% of peersCA avg$26,970Fines · denials2 · 0
What is fines in the last three years?
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Why it matters
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cycles28citations
5inspection dates
1actual harm (G–I)
0immediate jeopardy (J–L)
Dec 29, 2025most recent
Citations by monthAug 2019 – Dec 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Click to filter the findings below
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Dec 29, 2025Cycle 1worst E · no actual harm
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Jan 16, 2026
Apr 10, 2025Cycle 1worst D · no actual harm
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected May 2, 2025
- 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 May 2, 2025
Mar 5, 2025Cycle 1worst G · actual harm$9,295
- F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Mar 27, 2025
Mar 27, 2023Cycle 2worst F · no actual harm$3,250
- F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Nutrition and DietaryF · widespreadCorrected May 1, 2023
- F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Nutrition and DietaryF · widespreadCorrected May 1, 2023
- F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Nutrition and DietaryF · widespreadCorrected May 1, 2023
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected May 1, 2023
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected May 1, 2023
- F847Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.AdministrationD · isolatedCorrected May 1, 2023
- F865Have a plan that describes the process for conducting QAPI and QAA activities.AdministrationE · patternCorrected May 1, 2023
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected May 1, 2023
- F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Infection ControlF · widespreadCorrected May 1, 2023
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 1, 2023
- F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalF · widespreadCorrected May 1, 2023
- 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 May 1, 2023
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected May 1, 2023
- 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.Pharmacy ServiceF · widespreadCorrected May 1, 2023
Aug 30, 2019Cycle 3worst E · no actual harm
- F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalD · isolatedCorrected Oct 28, 2019
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Oct 28, 2019
- 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 Oct 28, 2019
- 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 Oct 28, 2019
- F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and CareE · patternCorrected Oct 28, 2019
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Oct 28, 2019
- 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.Pharmacy ServiceD · isolatedCorrected Oct 28, 2019
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Oct 28, 2019
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Oct 28, 2019
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Oct 28, 2019
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.99hrs
- Registered nursesRN hours only0.44hrs
- Licensed practical nursesLPN hours1.00hrs
- Nurse aidesCNA hours2.55hrs
- Weekend nursingAll staff on Saturdays and Sundays3.65hrs
- California average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better25%Above 85% of peersCA avg 38%
- RN turnoverRegistered nurses only—Not ranked by CMS
- Administrators who leftIn the past year1Leadership changed
- Occupancy70 certified beds · ~38 residents a day54%Above only 2% of peersCA avg 88%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $12,545In fines
- 2Fines
- 0Payment denials
- $26,970CA avg in fines
Above only 33% of peersFewer fines than 33% of rated homes in California
Actions on record
- Mar 5, 2025Civil money penalty$9,295
- Mar 27, 2023Civil money penalty$3,250
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- The Ensign Group324 facilities in the chain3.2★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Rural
- Ownership change
- None in the last 12 months
People and entities on file
Direct owners (5%+)
- Flagstone Healthcare North LLC
Indirect owners (5%+)
- The Ensign Group INC
Operational or managerial control
- Twomagnets LLC
- Shawndee Gamble
- Seema Rao
Corporate officers
- Soon Burnam
- Chad Keetch
- Adam Willits
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 056215 · 64 NORTHBROOK WAY, WILLITS, CA, 95490.
- Percentiles compare this facility with every rated nursing home in California and Mendocino 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.
