Based on observation, interview and record review, the facility failed to ensure a residents room did not accommodate no more than four residents per room for two of eight Resident rooms (rooms [ROOM NUMBERS]).This deficient practice had the potential to result in inadequate useable living space for the residents and working space for the healthcare providers.Findings: During a review of the facility Room Waiver letter, dated 8/11/2026, submitted by the Facility Administrator (FA), the facility room waiver letter indicated that resident rooms [ROOM NUMBERS] have six beds per room. …
F911 citations in California
Environmental Deficiencies
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F911 more often than its own record predicts
6.86 times the share F911 takes of citations nationally.
Of every deficiency written in California in 2025, this is the portion that was F911.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F911 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.
Based on observation, interview, and record review, the facility failed to meet the requirement for no more than four residents per room for two (2) out of 60 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]). This failure had the potential to adversely affect the delivery of care, quality of life, safety, and violate the resident's rights for privacy. Findings During the entrance conference interview with the Director of Nursing (DON) on 8/10/2026 at 8:03 AM, the DON stated that two rooms in the facility were occupied by more than four residents in each room, but the facility had a waiver (a permit approved by Centers for Medicare & Medicaid Services for rooms that did not meet the regulation requirement) in place and would like to request a continuing waiver this year. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.25% | 9.33× |
| 2024 | 0.29% | 6.97× |
| 2025 | 0.30% | 6.86× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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