Home›Browse›California›Oakland›Garfield Neurobehavioral Center

Nursing homeFAID #1251

Garfield Neurobehavioral Center

1451 28TH AVENUE, OAKLAND, CA, 94601

(510) 261-9191

96 licensed beds

★★★★★3/5CMS Five-Star overall2/5 health inspections5/5 staffing3/5 quality measuresSource: CMS Care Compare

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Address

1451 28th Avenue

Oakland, CA 94601

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Public record summary

What we can show you for free.

Bed capacity

CMS facility ID

05A396

Care type

Nursing home

County

Alameda

Facility name

Garfield Neurobehavioral Center

Street address

1451 28TH AVENUE

City / state / ZIP

Oakland, CA 94601

Phone

(510) 261-9191

About this facility — Garfield Neurobehavioral Center

Garfield Neurobehavioral Center is a Medicare/Medicaid-certified skilled nursing facility in Oakland, California. It is licensed for 96 beds — close to the median for skilled nursing facilities in California (98 beds).

It is one of 55 senior care facilities in Oakland and 1,165 skilled nursing facilities across California. Families comparing options should weigh inspection history, ownership record, and litigation — not just the tour — before deciding.

Federal inspectors have cited Garfield Neurobehavioral Center 51 times across 9 inspections in the last three years, including 3 food-safety citations; no federal fines are on record. Every citation is listed, dated, and graded in the inspection record below.

This listing draws on federal CMS Nursing Home Compare records, and was last updated on August 31, 2026. Background reports are compiled from primary sources — state inspection files, federal CMS data, corporate registrations, and court records — at the time of order.

Facility background

What the public record shows.

Ownership & operator

Ownership type

For profit - Corporation

Regulatory standing

Licensed / certified since

1992-07-13

CMS overall rating

3 of 5 stars

Health deficiencies

9 at the last standard inspection

Federal fines

None on record

Last standard inspection

2025-08-01

Nurse staffing

4.6 hours per resident per day

Services & coverage

Licensed beds

Medicare

Accepted

Medicaid

Accepted

Compiled from CMS Nursing Home Compare · last verified 2026-08-31. Facilities can submit a correction.

Inspection record

Every citation, dated and graded.

Kitchen & food safety

Federal surveyors inspect the kitchen at every standard visit. This facility has 3 food-safety citations on its three-year record — flagged below among the inspections.

2026-07-02Health inspectionComplaint-triggered1 citation

F-0600

D · No harm foundFrom a complaint

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

2025-08-01Health inspection8 citations

F-0600

J · Immediate jeopardy

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-08-14

F-0607

D · No harm found

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2025-08-14

F-0609

D · No harm found

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-08-14

F-0656

D · No harm found

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-08-14

F-0759

E · No harm found

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-08-14

F-0761

E · No harm found

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 2025-08-14

F-0812

E · No harm foundFood safety

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-08-14

F-0880

E · No harm found

Provide and implement an infection prevention and control program.

Corrected 2025-08-14

6 earlier / fire-safety inspections (42 citations)

2025-02-21Health inspectionComplaint-triggered1 citation

F-0600

G · Actual harmFrom a complaint

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-02-28

2024-03-21Health inspection5 citations

F-0584

D · No harm found

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 2024-04-06

F-0641

D · No harm found

Ensure each resident receives an accurate assessment.

Corrected 2024-04-06

F-0761

E · No harm found

Corrected 2024-04-06

F-0812

E · No harm foundFood safety

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-04-06

F-0814

E · No harm foundFood safety

Dispose of garbage and refuse properly.

Corrected 2024-04-06

2024-03-18Health inspectionComplaint-triggered3 citations

F-0689

D · No harm foundFrom a complaint

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-04-06

F-0755

D · No harm foundFrom a complaint

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-04-06

F-0760

D · No harm foundFrom a complaint

Ensure that residents are free from significant medication errors.

Corrected 2024-04-06

2025-08-01Fire-safety inspection7 citations

E-0039

F · No harm found

Conduct testing and exercise requirements.

Corrected 2025-08-13

K-0161

D · No harm found

Use approved construction type or materials.

Corrected 2025-08-06

K-0293

D · No harm found

Have properly located and lighted "Exit" signs.

Corrected 2025-08-06

K-0353

C · No harm found

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-08-06

K-0918

F · No harm found

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-08-18

K-0919

D · No harm found

Meet requirements for the use of electrical equipment.

Corrected 2025-08-06

K-0920

D · No harm found

Ensure proper usage of power strips and extension cords.

Corrected 2025-08-06

2024-03-21Fire-safety inspection12 citations

E-0026

D · No harm found

Establish roles under a Waiver declared by secretary.

Corrected 2024-04-05

E-0039

D · No harm found

Conduct testing and exercise requirements.

Corrected 2024-04-05

K-0161

E · No harm found

Use approved construction type or materials.

Corrected 2024-04-05

K-0321

D · No harm found

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-04-05

K-0324

D · No harm found

Provide properly protected cooking facilities.

Corrected 2024-04-05

K-0345

D · No harm found

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-04-05

K-0353

D · No harm found

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-04-05

K-0355

D · No harm found

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-04-05

K-0363

D · No harm found

Install corridor and hallway doors that block smoke.

Corrected 2024-04-05

K-0711

F · No harm found

Provide a written emergency evacuation plan.

Corrected 2024-04-05

K-0919

D · No harm found

Meet requirements for the use of electrical equipment.

Corrected 2024-04-05

K-0920

D · No harm found

Ensure proper usage of power strips and extension cords.

Corrected 2024-04-05

2022-01-06Fire-safety inspection14 citations

E-0023

D · No harm found

Establish policies and procedures for medical documentation.

Corrected 2022-02-02

E-0030

D · No harm found

List the names and contact information of those in the facility.

Corrected 2022-02-02

E-0031

D · No harm found

Provide emergency officials' contact information.

Corrected 2022-02-02

E-0032

D · No harm found

Provide primary/alternate means for communication.

Corrected 2022-02-02

K-0211

D · No harm found

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2022-02-02

K-0321

D · No harm found

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2022-02-02

K-0324

D · No harm found

Provide properly protected cooking facilities.

Corrected 2022-02-02

K-0353

D · No harm found

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-02-02

K-0355

D · No harm found

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2022-02-02

K-0363

D · No harm found

Install corridor and hallway doors that block smoke.

Corrected 2022-02-02

K-0711

D · No harm found

Provide a written emergency evacuation plan.

Corrected 2022-02-02

K-0712

D · No harm found

Have simulated fire drills held at unexpected times.

Corrected 2022-02-02

K-0918

D · No harm found

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-02-02

K-0923

D · No harm found

Have proper medical gas storage and administration areas.

Corrected 2022-02-02

Citations and penalties from the CMS Provider Data Catalog (three-year survey window, refreshed monthly). Severity codes follow the federal scope/severity grid; “Immediate jeopardy” is the most serious grade CMS issues. CCN 05A396.

Inside your report

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Ownership & corporate history

Primary tier

Prior operators & transfers

Corporate network & affiliates

Owners' other facilities

· · 2 more

Inspection citations — last 5 years

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The 51 citations above are shown free. The report takes each one and explains it in plain English — what the tag requires, how serious the scope/severity grade really is, whether it recurred across surveys — plus the five-year pattern a single inspection can't show.

Civil & criminal lawsuits

Advanced tier only

Active civil suits

Federal dockets

CDC infection data

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Original records

Sources we pull for this facility.

Source

CMS Nursing Home Compare

data.cms.gov Provider Data Catalog

Last verified 2026-08-31

Source

Secretary of State filings

Entity & officer search

Pulled when a report is ordered

Source

PACER federal dockets

pacer.uscourts.gov

Pulled when a report is ordered