Based on interview and record review, the facility failed to ensure a state- licensed Nursing Home Administrator was overseeing facility operations when the unlicensed Operations Manager (OM) had assumed the role of administrator for more than 11 months.This failure resulted in residents, staff and facility operations being supervised and directed by unqualified administrative leadership for more than 11 months.During a record review of state nursing home administrator licensing database titled, Licensing and Certification License Verification Page, the database indicated OM did not have a nursing home administrator license.During a review of state nursing home database titled, ELMS, the database indicated ADM 2 was the reported administrator of the facility from 11/4/2020 to 3/13/2023. …
F839 citations in California
Administration Deficiencies
Employ staff that are licensed, certified, or registered in accordance with state laws.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F839 more often than its own record predicts
1.01 times the share F839 takes of citations nationally.
Of every deficiency written in California in 2025, this is the portion that was F839.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F839 findings written in California, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.07% | 1.75× |
| 2024 | 0.06% | 1.11× |
| 2025 | 0.06% | 1.01× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction