Map showing the location of GOLDEN SONORA CARE CENTER in SONORA, California
19929 GREENLEY ROAD, SONORA, CA, 95370

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • CaliforniaLowest tier among peers1,154 rated homes · average 3.2★
  • 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 star3★−0.1 vs CA avg
  • Quality measuresCan add or remove a star1★−3.1 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.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among 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 turnover3★Above only 27% 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 assessments1★Lowest tier among 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 staff4.07hrsAbove only 32% 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 only0.27hrsAbove only 8% 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 better58%Above only 6% of peersCA avg38%RN turnover54%
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$93,308Above only 9% of peersCA avg$26,970Fines · denials2 · 1
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 cycles
90citations
25inspection dates
2actual harm (G–I)
0immediate jeopardy (J–L)
Dec 9, 2025most recent

Citations by monthApr 2023 – Dec 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Dec 9, 20251 citationCycle 1worst D · no actual harm
  1. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrection pending
Sep 2, 20251 citationCycle 1worst D · no actual harm
  1. 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 Sep 3, 2025
Aug 7, 202523 citationsCycle 1worst E · no actual harm
  1. 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 Aug 8, 2025
  2. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Aug 8, 2025
  3. 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 ServiceE · patternCorrected Aug 8, 2025
  4. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Aug 8, 2025
  5. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryE · patternCorrected Aug 8, 2025
  6. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Aug 8, 2025
  7. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Aug 8, 2025
  8. F881Implement a program that monitors antibiotic use.Infection ControlE · patternCorrected Aug 8, 2025
  9. F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalE · patternCorrected Aug 8, 2025
  10. 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 Aug 8, 2025
  11. F814Dispose of garbage and refuse properly.Nutrition and DietaryD · isolatedCorrected Aug 8, 2025
  12. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Aug 8, 2025
  13. F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Aug 8, 2025
  14. F583Keep residents' personal and medical records private and confidential.Resident RightsE · patternCorrected Aug 8, 2025
  15. 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 Aug 8, 2025
  16. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningE · patternCorrected Aug 8, 2025
  17. 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 Aug 8, 2025
  18. 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 Aug 8, 2025
  19. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Aug 8, 2025
  20. F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and CareD · isolatedCorrected Aug 8, 2025
  21. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Aug 8, 2025
  22. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Aug 8, 2025
  23. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Aug 8, 2025
Jul 1, 20251 citationCycle 1worst D · no actual harm
  1. 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 1, 2025
Jun 11, 20251 citationCycle 1worst D · no actual harm
  1. F687Provide appropriate foot care.Quality of Life and CareD · isolatedCorrected Jun 11, 2025
Feb 19, 20252 citationsCycle 1worst D · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Feb 19, 2025
  2. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Feb 19, 2025
Jan 29, 20251 citationCycle 2worst D · no actual harm
  1. 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 Jan 29, 2025
Oct 2, 20241 citationCycle 2worst D · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Oct 8, 2024
Jul 23, 20241 citationCycle 2worst D · no actual harm
  1. F626Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.Resident RightsD · isolatedCorrected Jul 29, 2024
Jul 18, 20242 citationsCycle 2worst D · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jul 29, 2024
  2. 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 Jul 29, 2024
Jun 20, 202415 citationsCycle 2worst E · no actual harm
  1. F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningD · isolatedCorrected Jun 20, 2024
  2. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Jun 20, 2024
  3. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Jun 20, 2024
  4. F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsD · isolatedCorrected Jun 20, 2024
  5. F567Honor the resident's right to manage his or her financial affairs.Resident RightsE · patternCorrected Jun 20, 2024
  6. 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 20, 2024
  7. F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Quality of Life and CareD · isolatedCorrected Jun 20, 2024
  8. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Jun 20, 2024
  9. F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Jun 20, 2024
  10. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Jun 20, 2024
  11. F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Pharmacy ServiceD · isolatedCorrected Jun 20, 2024
  12. 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 Jun 20, 2024
  13. 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 DietaryE · patternCorrected Jun 20, 2024
  14. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Jun 20, 2024
  15. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jun 20, 2024
May 17, 20241 citationCycle 2worst D · no actual harm
  1. F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningD · isolatedCorrected May 23, 2024
Apr 11, 20241 citationCycle 2worst E · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected Apr 19, 2024
Mar 27, 20241 citationCycle 2worst E · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Apr 17, 2024
Mar 5, 20241 citationCycle 2worst D · no actual harm
  1. 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 Apr 5, 2024
Feb 26, 20241 citationCycle 2worst G · actual harm$56,843, payment denial
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Mar 18, 2024
Jan 9, 20242 citationsCycle 3worst D · no actual harm
  1. F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Pharmacy ServiceD · isolatedCorrected Feb 9, 2024
  2. 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 Feb 9, 2024
Dec 6, 20231 citationCycle 3worst D · no actual harm
  1. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Jan 3, 2024
Oct 20, 20231 citationCycle 3worst D · no actual harm
  1. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Nov 8, 2023
Oct 17, 20231 citationCycle 3worst D · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Oct 20, 2023
Oct 11, 20231 citationCycle 3worst D · no actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Oct 30, 2023
Jun 22, 202325 citationsCycle 3worst G · actual harm$36,465
  1. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Jul 19, 2023
  2. 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 PlanningE · patternCorrected Jul 19, 2023
  3. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Jul 19, 2023
  4. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Jul 19, 2023
  5. F679Provide activities to meet all resident's needs.Quality of Life and CareD · isolatedCorrected Jul 19, 2023
  6. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Jul 19, 2023
  7. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected Jul 19, 2023
  8. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Jul 19, 2023
  9. 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 Jul 19, 2023
  10. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Jul 19, 2023
  11. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryD · isolatedCorrected Jul 19, 2023
  12. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Jul 19, 2023
  13. 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 Jul 19, 2023
  14. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jul 19, 2023
  15. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Jul 19, 2023
  16. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Jul 19, 2023
  17. F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Resident RightsD · isolatedCorrected Jul 19, 2023
  18. 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 Jul 19, 2023
  19. 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 19, 2023
  20. F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Quality of Life and CareD · isolatedCorrected Jul 19, 2023
  21. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected Jul 19, 2023
  22. F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Jul 19, 2023
  23. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceE · patternCorrected Jul 19, 2023
  24. F687Provide appropriate foot care.Quality of Life and CareD · isolatedCorrected Jul 19, 2023
  25. F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and CareG · isolatedCorrected Jul 19, 2023
May 31, 20231 citationCycle 3worst D · no actual harm
  1. F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningD · isolatedCorrected Jun 16, 2023
May 10, 20233 citationsCycle 3worst D · no actual harm
  1. F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Pharmacy ServiceD · isolatedCorrected May 30, 2023
  2. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected May 30, 2023
  3. 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 May 30, 2023
Apr 4, 20231 citationCycle 3worst D · no actual harm
  1. 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 19, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined4.07hrsAbove only 32% of peers−0.44 vs CA avg
  • Registered nursesRN hours only0.27hrsAbove only 8% of peers−0.38 vs CA avg
  • Licensed practical nursesLPN hours1.29hrs
  • Nurse aidesCNA hours2.52hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.79hrs
  • California average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better58%Above only 6% of peersCA avg 38%
  • RN turnoverRegistered nurses only54%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy210 certified beds · ~173 residents a day83%Above only 18% of peersCA avg 88%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $93,308In fines
  • 2Fines
  • 1Payment denial
  • $26,970CA avg in fines
Above only 9% of peersFewer fines than 9% of rated homes in California

Actions on record

  1. Feb 26, 2024Civil money penalty$56,843
  2. Feb 26, 2024Denial of payment for new admissionsfrom Mar 29, 2024
  3. Jun 22, 2023Civil money penalty$36,465

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Golden SNF Operations7 facilities in the chain2.3★ 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%+)
  • Sonora Operations Holdings LLC
Indirect owners (5%+)
  • Ch Cafive Holdings LLC
  • Cw Cafive Holdings LLC
  • Witzcorp LLC
  • Yisroel Herzka
  • Chava Wolofsky
  • Yitzchok Yenowitz
Operational or managerial control
  • Couve Healthcare Consulting LLC
  • Sonora Opco Manager LLC
  • Sonora SNF Consulting LLC
  • Sonora SNF Operations LLC
  • Veritas Health Solutions LLC
  • Karen Barias
  • Steven Earl
  • Genesis Leininger
  • +4 more
Corporate officers
  • Shimon Spielman
  • Yitzchok Yenowitz

Person Organization

Sources & notes

Public data, updated quarterly

Data 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 555736 · 19929 GREENLEY ROAD, SONORA, CA, 95370.
  • Percentiles compare this facility with every rated nursing home in California and Tuolumne 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.

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