GARFIELD NEUROBEHAVIORAL CENTER
1451 28TH AVENUE, OAKLAND, CA 94601
Exceeds federal staffing minimum — top tier inspection record.
Quality Breakdown
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RN Staffing
Registered nurse time each resident receives daily. Federal minimum: 0.55 hrs.
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0.83 ✓ Meets federal minimum |
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Health Deficiencies
Violations found during federal inspections over the last 3 years.
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8 |
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CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
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Quality: ★★★★☆ (4/5)
Staffing: ★★★★★ (5/5)
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NursingHomeGrade Score
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83/100 |
Data last updated: April 12, 2026
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
Most recent inspection (August 1, 2025)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected August 14, 2025
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected August 14, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected August 14, 2025
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected August 14, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected August 14, 2025
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected August 14, 2025
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected August 14, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected August 14, 2025
Inspection cycle 2 (February 21, 2025)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected February 28, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected April 6, 2024
Dispose of garbage and refuse properly.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected April 6, 2024
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected April 6, 2024
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected April 6, 2024
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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected April 6, 2024
Inspection cycle 3 (March 18, 2024)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected April 6, 2024
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected April 6, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 6, 2024
Quality Assurance & Integrity
NursingHomeGrade is strictly independent. We do not accept payments from facilities. Our grades are calculated solely from federal CMS datasets.
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