San Leandro Healthcare Center
SAN LEANDRO HEALTHCARE CENTER in SAN LEANDRO, CA — inspection on November 26, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 1's admission Record (AR) dated 11/18/25, the AR indicated Resident 1 was admitted to the facility in August 2025 with diagnoses that included major depressive disorder (a mental health condition causing persistent sadness, hopelessness, and loss of interest in activities, significantly impacting daily life) and post-traumatic stress disorder (a mental health condition that can develop after experiencing or witnessing a traumatic event, such as combat, assault, or a natural disaster).During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) assessment dated [DATE], the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15.
A BIMS score of 13-15 is an indication of intact cognitive status.During a telephone interview on 11/19/25 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated hearing loud arguing around midnight on 9/17/25. LVN 1 stated she separated Resident 1 and CNA 1, who were arguing. Resident 1 said he requested CNA 1 to unlock the bathroom door, but CNA 1 did not assist. LVN 1 stated both Resident 1 and CNA 1 became somewhat aggressive, and she heard CNA 1 tell Resident 1 to go to his room and return to sleep in a loud manner.
However, Resident 1 calmed down after being separated.During a telephone interview on 11/18/25 at 3:36 p.m. with CNA 1, CNA 1 repeatedly stated during the interview that Resident 1 refused to listen after CNA 1 explained that the bathroom door was not locked.During a review of Resident 1's Interdisciplinary Team (IDT, a group composed of individuals from different departments of the facility) Note dated 9/17/25, the IDT Note indicated Resident 1 had a verbal altercation with CNA 1, resulting in Resident 1 feeling threatened and unable to sleep through the night.During a review of the facility's policy and procedure (P&P) titled Dignity last revised February 2021, the P&P indicated that each resident shall be cared for in a manner that promotes feelings of self-worth and self-esteem and sense of well-being.
Staff are required to always speak to residents respectfully.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/26/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
San Leandro Healthcare Center
368 Juana Avenue San Leandro, CA 94577
SUMMARY STATEMENT OF DEFICIENCIES
During a follow-up interview on 11/18/25 at 12:33 p.m. with SW, SW stated the receptionist on duty will call the resident's family to arrange a care plan meeting upon admission. SW could not show any documentation in the clinical record of any scheduled care plan meeting in the clinical record.During an interview on 11/19/25 at 10:42 a.m. with Receptionist (REC) 1, REC 1 stated, initial care conferences are scheduled by the receptionist on duty for newly admitted residents.
For Resident 2, who was not a newly admitted resident, and was only returning from the hospital, it was the responsibility of SW to schedule the subsequent care conference meeting.During a review of the facility's policy and procedure (P&P) titled Resident Participation-Assessment/Care Plans last revised February 2021, the P&P indicated: The residents and any legal representative are encouraged to attend and participate in the development of the person-centered care plan .
The resident and the resident's representative's right to participate includes the right to request meetings .
The facility provides sufficient notice in advance of the meeting.
Facility ID: