Based on observation, interview, and record review, the facility failed to provide sufficient space in the East Wing dining room (the smaller of two facility dining rooms) to safely and comfortably accommodate 16 of 16 (Residents 5, 17, 26, 30, 31, 46, 53, 63, 65, 66, 72, 78, 81, 86, 99, and 108) sampled residents who ambulate (walk), use walkers and wheelchairs (mobility devices). During meal times (breakfast, lunch and dinner) facility staff configured tables, chairs and mobility devices in such a way as to block the entrances and exits of the dining room and to not provide comfortable spacing between residents. …
F920 citations in California
Environmental Deficiencies
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F920 more often than its own record predicts
1.37 times the share F920 takes of citations nationally.
Of every deficiency written in California in 2025, this is the portion that was F920.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F920 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 and interview, the facility failed to ensure the dining room was accessible and had space to accommodate the 132 Residents who reside at the facility. This failure had the potential to negatively affect the resident's social interaction, physical, mental, and psychosocial well-being. Findings: During a concurrent observation and interview on 2/24/25 at 12:13 p.m. with Assistant Director of Nursing (ADON) in the dining room, the dining room door was closed and had a coded lock. There were seven round tables. There was a seating chart on the wall that listed where 15 residents would sit. Eight residents were waiting for lunch to be served. ADON stated they usually have around eight residents in the dining room at one time. …
Based on observation, interview and record review, the facility failed to meet the interests and psychosocial well-being of each resident by not providing tablecloths for all the tables during meal time. The failure to provide to meet the residents needs created feelings of disappointment and dissatisfaction. Findings: During lunch observation on (MONTH) 9, 2019 at 12:50 p.m., two tables were observed without tablecloths with eight residents eating lunch at the table. During an interview with the Activity Aide 2 (AA2) on (MONTH) 9, 2019 at 12:50 p.m., stated the tables the resident are eating lunch at are used for sensory experience and it always been like that, with no tablecloth on them. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.02% | 1.55× |
| 2024 | 0.02% | 1.74× |
| 2025 | 0.01% | 1.37× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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