The SNF Report
Home › Facilities › California › GARFIELD NEUROBEHAVIORAL CENTER

GARFIELD NEUROBEHAVIORAL CENTER

1451 28TH AVENUE
OAKLAND, CA 94601 · 5102619191 · Alameda County
⚠ Abuse citation on record. This facility has been cited for abuse or neglect in the CMS data — see the citation list below.

CMS Star Ratings

Overall★★★★★
Health inspection★★★★★
Staffing★★★★★
Quality measures★★★★★

Facility Facts

Certified beds96
OwnershipFor profit - Corporation
State rank#632

By the numbers

18
Health citations (3 cycles)
1
Immediate-jeopardy (J/K/L)
1
Actual-harm (G/H/I)
$0
Federal fines (CMPs)
The trend: Citations are rising — 9 in the most recent cycle versus 3 two cycles ago.

Recent Health Citations

Jul 2, 2026 · Health survey · F-tag 0600
D — No actual harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Aug 1, 2025 · Health survey · F-tag 0656
D — No actual harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Aug 1, 2025 · Health survey · F-tag 0609
D — No actual harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Aug 1, 2025 · Health survey · F-tag 0607
D — No actual harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Aug 1, 2025 · Health survey · F-tag 0880
E — No actual harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Aug 1, 2025 · Health survey · F-tag 0812
E — No actual harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Aug 1, 2025 · Health survey · F-tag 0761
E — No actual harm
Pharmacy Service Deficiencies
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.
Aug 1, 2025 · Health survey · F-tag 0759
E — No actual harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Aug 1, 2025 · Health survey · F-tag 0600
J — Immediate jeopardy
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Details
Correction status: Corrected Aug 14, 2025 — Deficient, Provider has date of correction
Inspection cycle: 1
Survey origin: Standard survey
Feb 21, 2025 · Health survey · F-tag 0600
G — Actual harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Details
Correction status: Corrected Feb 28, 2025 — Deficient, Provider has date of correction
Inspection cycle: 2
Survey origin: Complaint investigation
Mar 21, 2024 · Health survey · F-tag 0641
D — No actual harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Mar 21, 2024 · Health survey · F-tag 0584
D — No actual harm
Resident Rights Deficiencies
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.
Mar 21, 2024 · Health survey · F-tag 0814
E — No actual harm
Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
Mar 21, 2024 · Health survey · F-tag 0812
E — No actual harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Mar 21, 2024 · Health survey · F-tag 0761
E — No actual harm
Pharmacy Service Deficiencies
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.
Mar 18, 2024 · Health survey · F-tag 0760
D — No actual harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Mar 18, 2024 · Health survey · F-tag 0755
D — No actual harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Mar 18, 2024 · Health survey · F-tag 0689
D — No actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Showing the 18 most recent citations. View the full inspection record on CMS Care Compare →

More facilities in California →

How to read this page. Star ratings and citation counts come from the Centers for Medicare & Medicaid Services (CMS) Care Compare August 2026 dataset, covering the three most recent inspection cycles. Scope/severity letters: D–F no actual harm, G–I actual harm, J–L immediate jeopardy to resident health or safety.

Source: CMS Care Compare, August 2026 dataset. Updated quarterly. Figures come from public CMS records; contact info@theskilledreport.com for corrections.