# Monrovia Gardens Healthcare Center

Monrovia Gardens Healthcare Center is a Medicare/Medicaid-certified nursing home (Nursing home · SNF / NF) in Monrovia, CA, CMS Certification Number 055367, with 96 certified beds and about 82 residents per day. CMS rates it 1/5 overall (health inspections 1/5, staffing 3/5, quality measures 2/5).

## Key facts
- Status: Active CMS certification
- Address: 615 W. Duarte Rd., Monrovia, CA 91016 (Los Angeles County)
- Ownership type: For profit - Limited Liability company
- State license: California Department of Public Health (CDPH), Licensing & Certification; license 950000013 (facility ID 950000048), active, 95 licensed beds, licensee AG MONROVIA, LLC, as of 2026-10-16
- State enforcement (historical): 11 actions (0 class AA, 3 class A, 6 class B), 5 since 2019. California CDPH state citations and administrative penalties, 1997 to early 2024 (archived dataset). Separate from federal CMS deficiencies.
- Operator (legal business name): [Ag Monrovia, LLC](https://carefield.site/operator/op-ag-monrovia-llc)
- CMS chain: [Cambridge Healthcare Services](https://carefield.site/chain/cms-chain-98) — 32 facilities

- Phone: 6263584547
- Medicare Care Compare: https://www.medicare.gov/care-compare/details/nursing-home/055367

## Inspection record
30 inspections in the CMS window (latest 2026-07-15); 119 citations (104 health, 15 fire safety); 1 at actual harm and 0 at immediate jeopardy; 0 without a verified correction at last report. CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years; no citation in that window is not proof of a clean history.
- 2025-01-24 — [F-0689](https://carefield.site/deficiency/cms-f0689) Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. — scope/severity G (Actual harm (not immediate jeopardy)); Corrected; complaint survey
- 2026-07-15 — [F-0656](https://carefield.site/deficiency/cms-f0656) Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. — scope/severity D (No actual harm, potential for more than minimal harm); Corrected; complaint survey
- 2026-07-08 — [F-0677](https://carefield.site/deficiency/cms-f0677) Provide care and assistance to perform activities of daily living for any resident who is unable. — scope/severity D (No actual harm, potential for more than minimal harm); Corrected; complaint survey
- 2026-07-08 — [F-0803](https://carefield.site/deficiency/cms-f0803) 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. — scope/severity D (No actual harm, potential for more than minimal harm); Corrected; complaint survey
- 2026-07-08 — [F-0919](https://carefield.site/deficiency/cms-f0919) Make sure that a working call system is available in each resident's  bathroom and bathing area. — scope/severity D (No actual harm, potential for more than minimal harm); Corrected; complaint survey
- 2026-06-23 — [F-0552](https://carefield.site/deficiency/cms-f0552) Ensure that residents are fully informed and understand their health status, care and treatments. — scope/severity D (No actual harm, potential for more than minimal harm); Corrected; complaint survey
- 2026-06-23 — [F-0757](https://carefield.site/deficiency/cms-f0757) Ensure each resident’s drug regimen must be free from unnecessary drugs. — scope/severity E (No actual harm, potential for more than minimal harm); Corrected; complaint survey
- 2026-06-04 — [F-0676](https://carefield.site/deficiency/cms-f0676) Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. — scope/severity D (No actual harm, potential for more than minimal harm); Corrected; complaint survey
- 2026-03-03 — [F-0657](https://carefield.site/deficiency/cms-f0657) Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. — scope/severity E (No actual harm, potential for more than minimal harm); Corrected; complaint survey
- 2026-03-03 — [F-0687](https://carefield.site/deficiency/cms-f0687) Provide appropriate foot care. — scope/severity D (No actual harm, potential for more than minimal harm); Corrected; complaint survey
- 2026-03-03 — [F-0698](https://carefield.site/deficiency/cms-f0698) Provide safe, appropriate dialysis care/services for a resident who requires such services. — scope/severity D (No actual harm, potential for more than minimal harm); Corrected; complaint survey
- 2025-12-19 — [K-0321](https://carefield.site/deficiency/cms-k0321) Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. — scope/severity D (No actual harm, potential for more than minimal harm); Corrected
- 2025-12-19 — [K-0342](https://carefield.site/deficiency/cms-k0342) Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. — scope/severity D (No actual harm, potential for more than minimal harm); Corrected
- 2025-12-19 — [K-0345](https://carefield.site/deficiency/cms-k0345) Have approved installation, maintenance and testing program for fire alarm systems. — scope/severity F (No actual harm, potential for more than minimal harm); Corrected
- 2025-12-19 — [K-0351](https://carefield.site/deficiency/cms-k0351) Install an approved automatic sprinkler system. — scope/severity D (No actual harm, potential for more than minimal harm); Corrected
- 2025-12-19 — [K-0353](https://carefield.site/deficiency/cms-k0353) Inspect, test, and maintain automatic sprinkler systems. — scope/severity E (No actual harm, potential for more than minimal harm); Corrected
- 2025-12-19 — [K-0761](https://carefield.site/deficiency/cms-k0761) To conduct inspection, testing and maintenance of fire doors by qualified individuals. — scope/severity F (No actual harm, potential for more than minimal harm); Corrected
- 2025-12-19 — [K-0918](https://carefield.site/deficiency/cms-k0918) Have generator or other power source capable of supplying service within 10 seconds. — scope/severity F (No actual harm, potential for more than minimal harm); Corrected
- 2025-12-19 — [F-0550](https://carefield.site/deficiency/cms-f0550) Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. — scope/severity D (No actual harm, potential for more than minimal harm); Corrected
- 2025-12-19 — [F-0578](https://carefield.site/deficiency/cms-f0578) 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. — scope/severity E (No actual harm, potential for more than minimal harm); Corrected
- …and 99 more on the source page.

## Penalties
No fines or payment denials in the CMS penalties file (about the last three years).

## Staffing (PBJ, hours per resident per day)
- Total nurse: 4.28257 (state avg 4.54292, US 3.90085)
- RN: 0.47403
- Nursing staff turnover: 50%

## Owners and managers of record (CMS disclosures)
- [Ag Facilities Operations, LLC](https://carefield.site/owner/org-ag-facilities-operations-llc) — Direct owner, 100%, since 2003-08-11
- [Ira E Smedra Living Trust](https://carefield.site/owner/org-ira-e-smedra-living-trust) — Indirect owner, 48%, since 2003-08-11
- [Win Win Enterprises, LLC](https://carefield.site/owner/org-win-win-enterprises-llc) — Indirect owner, 48%, since 2003-08-11
- Jaspal Sohal — Operational / managerial control, since 2024-10-22
- Miguel Vidales — Operational / managerial control, since 2021-03-01
- [Cambridge Healthcare Services LLC](https://carefield.site/owner/org-cambridge-healthcare-services-llc) — Operational / managerial control, since 2013-10-01
- Donald Balacuit — Operational / managerial control, since 2024-04-18
- Julie Butenko — Operational / managerial control, since 2023-07-24
- Heidi Capela — Operational / managerial control, since 2023-04-03
- Hayley Cruz — Operational / managerial control, since 2025-04-01
- Lance Hassell — Operational / managerial control, since 2022-04-25
- Linda Lutz — Operational / managerial control, since 2012-02-01
- Paulina Salazar — Operational / managerial control, since 2020-12-14
- Ira Smedra — Operational / managerial control, since 2003-08-11
- Jaspal Sohal — Operational / managerial control, since 2024-10-22

## Nearby nursing homes
- [Monrovia Post Acute](https://carefield.site/facility/cms-055259) — 2.9 km, CMS overall 3/5
- [Santa Fe Lodge](https://carefield.site/facility/cms-555106) — 3 km, CMS overall 2/5
- [Mayflower Care Center](https://carefield.site/facility/cms-555374) — 3 km, CMS overall 4/5
- [Monte Vista Healthcare Center](https://carefield.site/facility/cms-055817) — 3 km, CMS overall 2/5
- [Huntington Drive Health and Rehabilitation Center](https://carefield.site/facility/cms-055376) — 3.7 km, CMS overall 1/5
- [Royal Terrace Healthcare](https://carefield.site/facility/cms-055541) — 3.7 km, CMS overall 4/5
- [Royal Oaks Manor-Bradbury Oaks](https://carefield.site/facility/cms-555503) — 3.9 km, CMS overall 4/5
- [Temple City Healthcare](https://carefield.site/facility/cms-056413) — 4.2 km, CMS overall 2/5

## Sources
- cms_provider_info: https://data.cms.gov/provider-data/api/1/datastore/query/4pq5-n9py/0?conditions%5B0%5D%5Bproperty%5D=cms_certification_number_ccn&conditions%5B0%5D%5Bvalue%5D=055367&conditions%5B0%5D%5Boperator%5D=%3D
- cms_ownership: https://data.cms.gov/provider-data/api/1/datastore/query/y2hd-n93e/0?conditions%5B0%5D%5Bproperty%5D=cms_certification_number_ccn&conditions%5B0%5D%5Bvalue%5D=055367&conditions%5B0%5D%5Boperator%5D=%3D
- cms_health_deficiencies: https://data.cms.gov/provider-data/api/1/datastore/query/r5ix-sfxw/0?conditions%5B0%5D%5Bproperty%5D=cms_certification_number_ccn&conditions%5B0%5D%5Bvalue%5D=055367&conditions%5B0%5D%5Boperator%5D=%3D
- cms_fire_safety_deficiencies: https://data.cms.gov/provider-data/api/1/datastore/query/ifjz-ge4w/0?conditions%5B0%5D%5Bproperty%5D=cms_certification_number_ccn&conditions%5B0%5D%5Bvalue%5D=055367&conditions%5B0%5D%5Boperator%5D=%3D
- cms_penalties: https://data.cms.gov/provider-data/api/1/datastore/query/g6vv-u9sr/0?conditions%5B0%5D%5Bproperty%5D=cms_certification_number_ccn&conditions%5B0%5D%5Bvalue%5D=055367&conditions%5B0%5D%5Boperator%5D=%3D
- cms_inspection_dates: https://data.cms.gov/provider-data/api/1/datastore/query/svdt-c123/0?conditions%5B0%5D%5Bproperty%5D=cms_certification_number_ccn&conditions%5B0%5D%5Bvalue%5D=055367&conditions%5B0%5D%5Boperator%5D=%3D

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Source page: https://carefield.site/facility/cms-055367 · Carefield — Senior Care Intelligence. Facts come from the CMS Provider Data Catalog (Medicare/Medicaid-certified nursing homes). Missing data never means no issue exists.