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California CDPH state citations and administrative penalties, 1997 to early 2024 (archived dataset). Separate from federal CMS deficiencies.
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D76 | E34 | F8 |
| Minimal | A· | B· |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Jul 15, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jul 8, 2026 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Jun 23, 2026 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jun 4, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Mar 3, 2026 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Dec 19, 2025 | Fire safety | Fire Safety Standard | 7 | Potential harm | — | Open → |
| Dec 19, 2025 | Health | Health Standard | 15 | Potential harm | — | Open → |
| Oct 31, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Sep 17, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Sep 3, 2025 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Aug 27, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Aug 5, 2025 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Jul 9, 2025 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| May 13, 2025 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Apr 24, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Mar 27, 2025 | Health | Health Complaint | 6 | Potential harm | — | Open → |
| Feb 26, 2025 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Feb 10, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jan 24, 2025 | Health | Health Complaint | 7 | Actual harm | — | Open → |
| Dec 31, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Dec 24, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Nov 25, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Oct 31, 2024 | Fire safety | Fire Safety Standard | 6 | Potential harm | — | Open → |
| Oct 31, 2024 | Health | Health Standard | 18 | Potential harm | — | Open → |
| Jun 21, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| May 29, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| May 9, 2024 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Oct 19, 2023 | Fire safety | Fire Safety Standard | 2 | Potential harm | — | Open → |
| Oct 19, 2023 | Health | Health Complaint, Health Standard | 17 | Potential harm | — | Open → |
| Oct 11, 2023 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Issued | Class | Type | Category | Final amount | Flags | Record |
|---|---|---|---|---|---|---|
| Dec 1, 2023 violation Oct 4, 2023 | Class B | Citation Citation B (HSC 1424) | Patient Care | $3,000 | Closed | 950019434 |
| Dec 29, 2022 violation Nov 11, 2022 | Class B | Citation Citation B (HSC 1424) | Patient Care | $3,000 | Open | 950018270 |
| Dec 29, 2022 violation Nov 11, 2022 | Class B | Citation Citation B (HSC 1424) | Patient Care | $3,000 | Open | 950018268 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D76 | E34 | F8 |
| Minimal | A· | B· | C· |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Jul 15, 2026 | F-0656 | 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 · Clinical care | D · Potential harm Isolated | Corrected Jul 17, 2026 | Complaint |
| Jul 8, 2026 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 10, 2026 | Complaint |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
32 facilities in 1 states. CMS chain ID 98.
Chain average overall rating (CMS): 2.6
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Ag Facilities Operations, LLC | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Aug 11, 2003 |
| Ira E Smedra Living Trust | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 48% | Aug 11, 2003 |
| Win Win Enterprises, LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 48% | Aug 11, 2003 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Ag Facilities Operations, LLC | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Aug 11, 2003 |
| Ira E Smedra Living Trust | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 48% | Aug 11, 2003 |
| Win Win Enterprises, LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 48% | Aug 11, 2003 |
| Jaspal Sohal | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Oct 22, 2024 |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Madera Rehabilitation & Nursing Center 517 South a Street, Madera, CA 93638 CCN 0551471 state class AA/A | 176 | Feb 24, 2026 | 1001 IJ6 harm | $374k | |
| Watsonville Nursing Center |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Monrovia Post Acute 1220 E. Huntington Drive, Duarte, CA 91010 CCN 0552592 state class AA/A | 2.9 km | 82 | Aug 4, 2026 | 732 harm | — | |
| Santa Fe Lodge 5053 Peck Rd., El Monte, CA 91732 CCN 5551061 state class AA/A | 3 km | 46 | Aug 25, 2026 | 671 IJ | — | |
| Mayflower Care Center 5043 Peck Rd, El Monte, CA 91732 CCN 5553741 state class AA/A | 3 km | 59 | Jul 17, 2026 | 55 | — | |
| Monte Vista Healthcare Center 802 Buena Vista Street, Duarte, CA 91010 CCN 0558175 state class AA/A | 3 km | 69 | Aug 28, 2026 | 751 open | — | |
| Huntington Drive Health and Rehabilitation Center 400 W. Huntinton Dr., Arcadia, CA 91007 CCN 0553763 state class AA/A | 3.7 km | 99 | Jul 24, 2026 | 99 | — | |
| Royal Terrace Healthcare 1340 Highland Ave., Duarte, CA 91010 CCN 0555412 state class AA/A | 3.7 km | 58 | Jun 26, 2026 | 46 | — | |
| Royal Oaks Manor-Bradbury Oaks 1763 Royal Oaks Drive, Duarte, CA 91010 CCN 5555033 state class AA/A | 3.9 km | 48 | Jan 2, 2026 | 512 harm | — | |
| Temple City Healthcare 5101 Tyler Avenue, Temple City, CA 91780 CCN 056413 | 4.2 km | 59 | Apr 17, 2026 | 671 open | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 055367 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 055367 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
| California CDPH Licensed Facility Listing CA | 950000048 | state_license, licensed_beds, licensee Linked to the CMS record by exact CCN. | Verified | Oct 16, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Dec 27, 2022 violation Oct 1, 2020 | AP NHPPD | Administrative Penalty AP - 3.2 Nursing-Hours-per-Patient-Day AP (HSC 1276.5) | DHPPD: 2 - 11 Days | $25,000 | Closed | 810018250 |
| Nov 10, 2021 violation Oct 1, 2019 | AP NHPPD | Administrative Penalty AP - 3.2 Nursing-Hours-per-Patient-Day AP (HSC 1276.5) | DHPPD: 2 - 11 Days | $15,000 | Closed | 810017067 |
| Dec 7, 2018 violation Oct 13, 2018 | Class B | Citation Citation B (HSC 1424) | Abuse/Facility Not Self Reported | $2,000 | Closed | 950014638 |
| Mar 21, 2017 violation Feb 10, 2017 | Class A | Citation Citation A (HSC 1424) | Patient Care | $20,000 | Closed | 950013068 |
| Mar 21, 2017 violation Feb 10, 2017 | Class A | Citation Citation A (HSC 1424) | Patient Care | $20,000 | Closed | 950013067 |
| Feb 24, 2017 violation Oct 26, 2016 | Class A | Citation Citation A (HSC 1424) | Patient Care | $16,000 | Closed | 950012992 |
| Oct 19, 2001 violation Sep 20, 2001 | Class B | Citation Citation B (HSC 1424) | Patient Care | $1,000 | Appealed Closed | 950001406 |
| Jan 22, 2001 violation Aug 30, 2000 | Class B | Citation Citation B (HSC 1424) | Patient Care | $1,000 | Closed | 950001380 |
| Jul 8, 2026 | F-0803 | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Jul 10, 2026 | Complaint |
| Jul 8, 2026 | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jul 10, 2026 | Complaint |
| Jun 23, 2026 | F-0552 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 13, 2026 | Complaint |
| Jun 23, 2026 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Jun 25, 2026 | Complaint |
| Jun 4, 2026 | F-0676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 5, 2026 | Complaint |
| Mar 3, 2026 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 23, 2026 | Complaint |
| Mar 3, 2026 | F-0687 | Provide appropriate foot care. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 23, 2026 | Complaint |
| Mar 3, 2026 | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 23, 2026 | Complaint |
| Dec 19, 2025 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 19, 2025 |
| Dec 19, 2025 | K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 19, 2025 |
| Dec 19, 2025 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Dec 19, 2025 |
| Dec 19, 2025 | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 19, 2025 |
| Dec 19, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Dec 19, 2025 |
| Dec 19, 2025 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Dec 19, 2025 |
| Dec 19, 2025 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Dec 19, 2025 |
| Dec 19, 2025 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 30, 2025 |
| Dec 19, 2025 | F-0578 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Dec 29, 2025 |
| Dec 19, 2025 | F-0606 | Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 29, 2025 |
| Dec 19, 2025 | F-0656 | 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 · Clinical care | D · Potential harm Isolated | Corrected Dec 29, 2025 |
| Dec 19, 2025 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 29, 2025 |
| Dec 19, 2025 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 29, 2025 |
| Dec 19, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Dec 29, 2025 |
| Dec 19, 2025 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 29, 2025 |
| Dec 19, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 29, 2025 |
| Dec 19, 2025 | F-0693 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 29, 2025 |
| Dec 19, 2025 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 29, 2025 |
| Dec 19, 2025 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Dec 29, 2025 |
| Dec 19, 2025 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Dec 29, 2025 |
| Dec 19, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Dec 29, 2025 |
| Dec 19, 2025 | F-0881 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Dec 29, 2025 |
| Oct 31, 2025 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 18, 2025 | Complaint |
| Sep 17, 2025 | F-0557 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 23, 2025 | Complaint |
| Sep 3, 2025 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 23, 2025 | Complaint |
| Sep 3, 2025 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Sep 24, 2025 | Complaint |
| Sep 3, 2025 | F-0808 | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Sep 23, 2025 | Complaint |
| Aug 27, 2025 | F-0908 | Keep all essential equipment working safely. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Sep 15, 2025 | Complaint |
| Aug 5, 2025 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Aug 27, 2025 | Complaint |
| Aug 5, 2025 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Aug 30, 2025 | Complaint |
| Aug 5, 2025 | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Aug 21, 2025 | Complaint |
| Jul 9, 2025 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 11, 2025 | Complaint |
| Jul 9, 2025 | F-0604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 27, 2025 | Complaint |
| Jul 9, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 11, 2025 | Complaint |
| May 13, 2025 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 14, 2025 | Complaint |
| May 13, 2025 | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 14, 2025 | Complaint |
| May 13, 2025 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 14, 2025 | Complaint |
| Apr 24, 2025 | F-0656 | 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 · Clinical care | D · Potential harm Isolated | Corrected May 13, 2025 | Complaint |
| Apr 24, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Apr 25, 2025 | Complaint |
| Mar 27, 2025 | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 1, 2025 | Complaint |
| Mar 27, 2025 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 1, 2025 | Complaint |
| Mar 27, 2025 | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 1, 2025 | Complaint |
| Mar 27, 2025 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Apr 1, 2025 | Complaint |
| Mar 27, 2025 | F-0806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Mar 28, 2025 | Complaint |
| Mar 27, 2025 | F-0807 | Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Mar 28, 2025 | Complaint |
| Feb 26, 2025 | F-0584 | 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 · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 21, 2025 | Complaint |
| Feb 26, 2025 | F-0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 20, 2025 | Complaint |
| Feb 26, 2025 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 20, 2025 | Complaint |
| Feb 10, 2025 | F-0656 | 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 · Clinical care | D · Potential harm Isolated | Corrected Feb 12, 2025 | Complaint |
| Jan 24, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Feb 20, 2025 | Complaint |
| Jan 24, 2025 | F-0576 | Ensure residents have reasonable access to and privacy in their use of communication methods. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 29, 2025 | Complaint |
| Jan 24, 2025 | F-0656 | 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 · Clinical care | D · Potential harm Isolated | Corrected Jan 29, 2025 | Complaint |
| Jan 24, 2025 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Feb 12, 2025 | Complaint |
| Jan 24, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 20, 2025 | Complaint |
| Jan 24, 2025 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Jan 27, 2025 | Complaint |
| Jan 24, 2025 | F-0726 | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Jan 29, 2025 | Complaint |
| Dec 31, 2024 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Jan 2, 2025 | Complaint |
| Dec 24, 2024 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 14, 2025 | Complaint |
| Dec 24, 2024 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 26, 2024 | Complaint |
| Nov 25, 2024 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 28, 2024 | Complaint |
| Oct 31, 2024 | E-0041 | Implement emergency and standby power systems. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Nov 30, 2024 |
| Oct 31, 2024 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 30, 2024 |
| Oct 31, 2024 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 30, 2024 |
| Oct 31, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 30, 2024 |
| Oct 31, 2024 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 30, 2024 |
| Oct 31, 2024 | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 30, 2024 |
| Oct 31, 2024 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 18, 2024 |
| Oct 31, 2024 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Oct 31, 2024 |
| Oct 31, 2024 | F-0578 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Nov 18, 2024 |
| Oct 31, 2024 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 18, 2024 |
| Oct 31, 2024 | F-0625 | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 20, 2024 |
| Oct 31, 2024 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 19, 2024 |
| Oct 31, 2024 | F-0656 | 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 · Clinical care | D · Potential harm Isolated | Corrected Nov 24, 2024 |
| Oct 31, 2024 | F-0676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 18, 2024 |
| Oct 31, 2024 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Nov 20, 2024 |
| Oct 31, 2024 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Nov 20, 2024 |
| Oct 31, 2024 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Nov 20, 2024 |
| Oct 31, 2024 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 15, 2024 |
| Oct 31, 2024 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Nov 5, 2024 |
| Oct 31, 2024 | F-0790 | Provide routine and 24-hour emergency dental care for each resident. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 19, 2024 |
| Oct 31, 2024 | F-0803 | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Nov 1, 2024 |
| Oct 31, 2024 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Nov 4, 2024 |
| Oct 31, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Nov 15, 2024 |
| Oct 31, 2024 | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 19, 2024 |
| Jun 21, 2024 | F-0600 | 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 · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 27, 2024 | Complaint |
| May 29, 2024 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 2, 2024 | Complaint |
| May 9, 2024 | F-0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 15, 2024 | Complaint |
| May 9, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected May 9, 2024 | Complaint |
| May 9, 2024 | F-0882 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected May 10, 2024 | Complaint |
| Oct 19, 2023 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 11, 2023 |
| Oct 19, 2023 | K-0341 | Install a fire alarm system that can be heard throughout the facility. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 11, 2023 |
| Oct 19, 2023 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 14, 2023 | Complaint |
| Oct 19, 2023 | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 14, 2023 |
| Oct 19, 2023 | F-0656 | 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 · Clinical care | D · Potential harm Isolated | Corrected Nov 14, 2023 |
| Oct 19, 2023 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 14, 2023 |
| Oct 19, 2023 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 14, 2023 |
| Oct 19, 2023 | F-0685 | Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 14, 2023 |
| Oct 19, 2023 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 14, 2023 |
| Oct 19, 2023 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 14, 2023 |
| Oct 19, 2023 | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Nov 14, 2023 |
| Oct 19, 2023 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Nov 14, 2023 |
| Oct 19, 2023 | F-0761 | 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 · Medication management | E · Potential harm Pattern | Corrected Nov 14, 2023 |
| Oct 19, 2023 | F-0770 | Provide timely, quality laboratory services/tests to meet the needs of residents. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Nov 14, 2023 |
| Oct 19, 2023 | F-0773 | Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Nov 14, 2023 |
| Oct 19, 2023 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Nov 14, 2023 |
| Oct 19, 2023 | F-0825 | Provide or get specialized rehabilitative services as required for a resident. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 14, 2023 |
| Oct 19, 2023 | F-0837 | Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Nov 14, 2023 |
| Oct 19, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Nov 14, 2023 |
| Oct 11, 2023 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Oct 25, 2023 | Complaint |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 3.93 (case-mix index 1.52).
| Miguel Vidales | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Mar 1, 2021 |
| Cambridge Healthcare Services LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Oct 1, 2013 |
| Donald Balacuit | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 18, 2024 |
| Julie Butenko | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 24, 2023 |
| Heidi Capela | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 3, 2023 |
| Hayley Cruz | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 1, 2025 |
| Lance Hassell | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 25, 2022 |
| Linda Lutz | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Feb 1, 2012 |
| Paulina Salazar | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Dec 14, 2020 |
| Ira Smedra | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Aug 11, 2003 |
| Jaspal Sohal | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Oct 22, 2024 |
| Miguel Vidales | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 1, 2021 |
| Jacob Wintner | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Aug 11, 2003 |
| Jacob Wintner | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Aug 11, 2003 |
| 615 W. Duarte, LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Oct 1, 2003 |
| Cambridge Healthcare Services LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Oct 24, 2025 |
| Win Win Enterprises, LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Oct 1, 2003 |
| Donald Balacuit | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Apr 18, 2024 |
| Julie Butenko | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jul 24, 2023 |
| Heidi Capela | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Apr 3, 2023 |
| Lance Hassell | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Apr 25, 2022 |
| Linda Lutz | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Feb 1, 2012 |
| Paulina Salazar | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Dec 14, 2020 |
| Ira Smedra | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Aug 11, 2003 |
| Jaspal Sohal | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Oct 24, 2025 |
| Miguel Vidales | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2021 |
| Jacob Wintner | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Aug 11, 2003 |
| 87 |
| Jan 9, 2026 |
56 |
| — |
| Merced Nursing & Rehabilitation Ctr 510 West 26th Street, Merced, CA 95340 CCN 055249 | 79 | Jul 17, 2026 | 46 | — |
| La Sierra Care Center 2424 M Street, Merced, CA 95340 CCN 055271 | 68 | Jan 23, 2026 | 61 | — |
| Valley Palms Care Center 13400 Sherman Way, N Hollywood, CA 91605 CCN 0552871 state class AA/A | 99 | May 18, 2026 | 1371 IJ1 harm | $34k |
| Huntington Drive Health and Rehabilitation Center 400 W. Huntinton Dr., Arcadia, CA 91007 CCN 0553763 state class AA/A | 99 | Jul 24, 2026 | 99 | — |
| Buena Vista Care Center 1440 S Euclid Avenue, Anaheim, CA 92802 CCN 055459 | 99 | May 11, 2026 | 1011 open | — |
| Glendale Post Acute Center 250 N. Verdugo Road, Glendale, CA 91206 CCN 0555234 state class AA/A | 136 | Jul 8, 2026 | 1123 IJ1 harm1 open | $162k |