All Saint's Maubert
15731 Maubert Avenue · San Leandro, CA · 94578 · 5104813200
14 certified beds For profit - Limited Liability company Chain: Pacs Group
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Staffing hours comfortably above national benchmarks.
- Inspection results have improved across recent cycles.
The composite number cleared 71 points, but Recommended is gated: inspection record below the Recommended bar. That rule is part of the published method.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
$131,856 in federal fines in the last 24 months
1 fine — CMS fines are reserved for verified, serious non-compliance.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 2 of 5 Staffing: 4 of 5 Quality measures: 1 of 5
| Total nurse hours / resident-day | 8.47 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 2.66 | 0.55–0.75 |
| Weekend hours / resident-day | 7.95 | ≈ weekday level |
| Nursing turnover / year | 54% | median 45% |
| Fines (3-yr window) | 1 · $131,856 |
Inspection citations (27 in the current record)
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Potential for harm · D August 22, 2025
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected December 11, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 22, 2025
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected December 11, 2025 · Resident Assessment and Care Planning
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Potential for harm · E August 22, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected December 11, 2025 · Resident Assessment and Care Planning
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Potential for harm · D August 22, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected December 11, 2025 · Quality of Life and Care
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Potential for harm · F August 22, 2025
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected December 11, 2025 · Nursing and Physician Services
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Potential for harm · E August 22, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected December 11, 2025 · Pharmacy Service
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Potential for harm · E August 22, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected December 11, 2025 · Pharmacy Service
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Potential for harm · F August 22, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected December 11, 2025 · Nutrition and Dietary
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Immediate jeopardy · L March 25, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected April 14, 2025 · Infection Control
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Potential for harm · E March 25, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected April 14, 2025 · Resident Assessment and Care Planning
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Potential for harm · F March 25, 2025 · found via complaint
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected April 14, 2025 · Infection Control
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Potential for harm · D February 5, 2024 · found via complaint
Ensure 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.
Corrected March 5, 2024 · Pharmacy Service
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Potential for harm · D October 26, 2023
Keep residents' personal and medical records private and confidential.
Corrected November 23, 2023 · Resident Rights
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Potential for harm · E October 26, 2023
Honor 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.
Corrected November 23, 2023 · Resident Rights
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Potential for harm · D October 26, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected November 23, 2023 · Resident Assessment and Care Planning
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Potential for harm · D October 26, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected November 23, 2023 · Quality of Life and Care
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Potential for harm · E October 26, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected November 23, 2023 · Quality of Life and Care
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Potential for harm · D October 26, 2023
Provide safe, appropriate pain management for a resident who requires such services.
Corrected November 23, 2023 · Quality of Life and Care
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Potential for harm · E October 26, 2023
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected November 23, 2023 · Nursing and Physician Services
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Potential for harm · D October 26, 2023
Ensure medication error rates are not 5 percent or greater.
Corrected November 23, 2023 · Pharmacy Service
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Potential for harm · E October 26, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected November 23, 2023 · Nutrition and Dietary
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Potential for harm · F October 26, 2023
Provide and implement an infection prevention and control program.
Corrected November 23, 2023 · Infection Control
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Potential for harm · D October 26, 2023
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected November 23, 2023 · Infection Control
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Potential for harm · E October 26, 2023
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected November 23, 2023 · Environmental
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Potential for harm · E October 13, 2022
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected November 15, 2022 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| March 25, 2025 | Fine | $131,856 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 555879 · certified since February 21, 2013. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.