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Within the realm of health care quality assessment, quality assurance and safety grading systems play a vital role in gauging hospital performance and communicating results to the general public. The primary objective of this review is to analyze the hospitals in California through the lens of Leapfrog Safety Grades and discuss the complex interplay of geographical location, hospital size, and larger system affiliation status. Leapfrog Safety Grades, hospital characteristics, and geographic information were collected. Hospitals were categorized by geographic region, size, rural/urban classification, and larger system affiliation status. Of the 284 hospitals included in the study, 95 were given a grade of A, 68 given a grade of B, 93 given a grade of C, 23 given a grade of D, 2 given a grade of F, and 3 were not graded. The vast majority of hospitals in California were classified as urban, with 183 falling under this category. The average number of hospital beds and SD was 227 ± 47.57. On average, hospitals that received a grade of D were significantly smaller in size than those that received a grade of A, while hospitals that received a grade of B or C were similar in size. A total of 107 hospitals were affiliated with a larger health care system. About 70% of hospitals affiliated with a system received an A or B grade, while 50% of unaffiliated hospitals received an A or B grade. Results of this study demonstrate a need for improving health care access and quality in medically underserved urban and rural areas. Hospitals affiliated with a larger health care system received higher grades than unaffiliated hospitals, suggesting that affiliation may also play a role in the implementation and mitigation of factors that contribute to Leapfrog Safety Grades., (Copyright © 2024 the American College of Medical Quality.)