Health inspection·January 7, 2026

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. Based on interview and record review, Facility 2 failed to document Resident 1's needs that could not be met by Facility 2 and the reasons why Resident 1's transfer or discharge was necessary. Facility 2 failed to appropriately communicate information concerning Resident 1's condition to Facility 1 prior to sending Resident 1 back to Facility 1. Facility 2 staff failed to properly admit Resident 1 to Facility 2 and then had Resident 1 transported back to Facility 1 from Facility 2, without properly discharging Resident 1 (from Facility 2) or having his medical needs assessed. This failure had the potential to result in a lapse in care when Resident 1 was sent back to Facility 1 from Facility 2 within a seven hour period on the same day.During a record review of Facility 1's document titled, Inpatient Medicine Discharge Summary, dated 7/11/25, the Inpatient Medicine Discharge Summary indicated Resident 1 had been admitted at Facility 1 from 6/12/2024 to 7/11/2025 with multiple diagnoses including dementia (a decline in mental ability severe enough to interfere with daily life) and altered mental status (a change in mental function). The Inpatient Medicine Discharge Summary also indicated Resident 1 was discharged on 7/11/25 at 10:30 a.m. from Facility 1. During an interview on 9/23/25 at 4:10 p.m. at Facility 2 with Registered Nurse 2 (RN2), RN2 stated when a new resident was going to be admitted , there will be a group text thread started on facility-issued phones so that they know when to expect the resident and can assign staff to care for them. During a concurrent interview and record review on 9/23/25 at 4:12 p.m. at Facility 2, text messages on RN2's facility-issued phone were reviewed. RN2 stated two text messages dated 7/10/25 sent from Registered Nurse 1 (RN1) indicated that Resident 1 was expected to arrive at Facility 2 around 10 a.m. on 7/11/25. During a concurrent interview and record review on 1/7/26 at 2:25 p.m. at Facility 2 with Assistant Director of Nursing (ADON), an Interfacility Transport Company's document titled, Receiving Facility Signature, dated 7/11/25 at 11:57 a.m., was reviewed. ADON stated the Receiving Facility Signature indicated that Resident 1 arrived at Facility 2 on 7/11/25 at 11:57 a.m. ADON also stated she signed the Receiving Facility Signature document because Resident 1 was unable to sign the document.During a concurrent phone interview and record review on 1/7/26 at 2:43 p.m. at Facility 2 with the Director of Nursing (DON), an email with the subject line, Male HMO Admission, dated 7/10/25 was reviewed. DON stated the Male HMO Admission email indicated Resident 1 was an expected admission and had approved insurance authorization. The Male HMO Admission email was sent on 7/10/25 at 4:29 p.m.During a follow-up phone interview on 1/7/26 at 2:45 p.m. at Facility 2 with DON, DON stated when Resident 1 arrived at Facility 2, it was determined that Resident 1 was not an appropriate fit for Facility 2. DON stated they offered Resident 1 food and then Resident 1 was sent back to Facility 1. DON stated there was no medical record created for Resident 1. DON stated Facility 2 did not document why Resident 1 was not appropriate for their facility [Facility 2]. DON also stated there was no nursing assessment done upon Resident 1's arrival to Facility 2. During a review of Facility 1's document titled, Medicine History and Physical, dated 7/11/25, the Medicine History (continued on next page) 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 (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056389 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vale Healthcare Center 13484 San Pablo Avenue San Pablo, CA 94806 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)