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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 | G3 | H· | I· |
| Potential harm | D55 | E44 | F7 |
| 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 | |
|---|---|---|---|---|---|---|
| Aug 12, 2026 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Aug 11, 2026 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| May 28, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| May 7, 2026 | Fire safety | Fire Safety Standard | 7 | Potential harm | — | Open → |
| May 7, 2026 | Health | Health Complaint, Health Standard | 18 | Potential harm | — | Open → |
| Mar 13, 2026 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Jan 30, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Dec 17, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Dec 12, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jul 2, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Mar 14, 2025 | Fire safety | Fire Safety Standard | 3 | Potential harm | — | Open → |
| Mar 14, 2025 | Health | Health Complaint, Health Standard | 31 | Potential harm | — | Open → |
| Jan 30, 2025 | Health | Health Complaint | 3 | Actual harm | — | Open → |
| Jan 8, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Sep 24, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Sep 5, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jun 17, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| May 13, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Mar 29, 2024 | Fire safety | Fire Safety Standard | 5 | Potential harm | — | Open → |
| Mar 29, 2024 | Health | Health Complaint, Health Standard | 15 | Actual harm | — | Open → |
| Jan 26, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jan 10, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Dec 4, 2023 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Nov 28, 2023 | Health | Health Complaint | 2 | Actual harm | — | Open → |
| Nov 21, 2023 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Nov 8, 2023 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Jan 8, 2025 | Civil money penalty (fine) | $18,564 | — | 555070|Fine|131063 |
| Mar 29, 2024 | Civil money penalty (fine) | $19,812 | — | 555070|Fine|130442 |
| Issued | Class | Type | Category | Final amount | Flags | Record |
|---|---|---|---|---|---|---|
| May 9, 2024 violation Mar 19, 2024 | Class A | Citation Citation A (HSC 1424) | Patient Care | $25,000 | Closed | 910020150 |
| Jan 10, 2024 violation Nov 2, 2023 | Class B | Citation Citation B (HSC 1424) | Patient Care | $3,000 | Closed | 910019582 |
| Dec 27, 2023 violation Oct 24, 2023 | Class B | Citation Citation B (HSC 1424) | Other · Infection Control | $3,000 | Open | 910019536 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G3 | H· | I· |
| Potential harm | D55 | E44 | F7 |
| Minimal | A· | B· | C1 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Aug 12, 2026 | 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 Sep 4, 2026 | ComplaintIDR |
| Aug 12, 2026 | 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 |
“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.
347 facilities in 17 states. CMS chain ID 507.
Chain average overall rating (CMS): 3.3
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Flagstone Healthcare South LLC | Organization | Direct owner | DIRECT OWNERSHIP INTEREST | not provided | Jan 30, 2006 |
| The Ensign Group Inc | Organization | Indirect owner | INDIRECT OWNERSHIP INTEREST | not provided | Jan 30, 2006 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Flagstone Healthcare South LLC | Organization | Direct owner | DIRECT OWNERSHIP INTEREST | not provided | Jan 30, 2006 |
| The Ensign Group Inc | Organization | Indirect owner | INDIRECT OWNERSHIP INTEREST | not provided | Jan 30, 2006 |
| Barry Port | Individual | Partner | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | not provided | Jul 11, 2025 |
| James Morrison | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Fairfield Post Acute Rehabilitation 1255 Travis Blvd, Fairfield, CA 94533 CCN 0550145 state class AA/A | 99 | Jun 25, 2026 | 57 | — | |
| Palomar Vista Healthcare Center 201 N Fig Street, Escondido, CA 92025 CCN 055067 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Intercommunity Healthcare & Rehabilitation Center 12627 Studebaker Road, Norwalk, CA 90650 CCN 0554574 state class AA/A | 1.1 km | 86 | Aug 28, 2026 | 662 harm2 open | $38k | |
| Norwalk Skilled Nursing & Wellness Centre, LLC 11510 Imperial Highway, Norwalk, CA 90650 CCN 5556683 state class AA/A | 1.4 km | 99 | Aug 26, 2026 | 891 IJ4 harm1 open | $73k | |
| Studebaker Healthcare Center 13226 Studebaker Rd, Norwalk, CA 90650 CCN 0564252 state class AA/AAbuse icon | 1.7 km | 99 | Apr 27, 2026 | 1261 IJ | $27k | |
| The Springs Post-Acute 10625 Leffingwell Road, Norwalk, CA 90650 CCN 0552973 state class AA/A | 2.6 km | 99 | Apr 23, 2026 | 802 IJ2 harm | $67k | |
| Lakewood Healthcare Center 12023 Lakewood Blvd., Downey, CA 90242 CCN 55509917 state class AA/ASFF CandidateAbuse icon | 2.8 km | 290 | Jun 8, 2026 | 1381 IJ3 harm | $129k | |
| Downey Community Health Center 8425 Iowa Street, Downey, CA 90241 CCN 5551282 state class AA/A | 3 km | 198 | Aug 27, 2026 | 63 | — | |
| Brookfield Healthcare Center 9300 Telegraph Road, Downey, CA 90240 CCN 0560142 state class AA/A | 3.4 km | 70 | Dec 5, 2025 | 371 harm | — | |
| Dept of State Hospitals - Metropolitan SNF 11401 South Bloomfield Avenue, Norwalk, CA 90650 CCN 5557312 state class AA/ASFF CandidateAbuse icon | 3.7 km | 102 | May 6, 2026 | 732 IJ3 harm | $136k |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 555070 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 555070 | 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 | 940000070 | 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
| Mar 5, 2021 violation Dec 31, 2020 | Class B | Citation Citation B (HSC 1424) | Patient Care | $2,000 | Closed | 910016329 |
| Aug 23, 2018 violation Jan 28, 2017 | Class B | Citation Citation B (HSC 1424) | Patient Care | $2,000 | Closed | 940014354 |
| Feb 5, 2007 violation Nov 18, 2006 | Class B | Citation Citation B (HSC 1424) | Patient Rights | $1,000 | Closed | 940003653 |
| Jan 24, 2007 violation Nov 18, 2006 | Class B | Citation Citation B (HSC 1424) | Patient Care | $1,000 | Closed | 940003630 |
| Jan 24, 2007 violation Nov 18, 2006 | Class B | Citation Citation B (HSC 1424) | Patient Care | $1,000 | Closed | 940003629 |
| Dec 19, 2002 violation Sep 16, 2002 | Class B | Citation Citation B (HSC 1424) | Patient Care | $800 | Closed | 940001478 |
| Mar 15, 2002 violation Feb 27, 2002 | Class B | Citation Citation B (HSC 1424) | Patient Care | $800 | Closed | 940001454 |
| Dec 21, 2000 violation Dec 1, 2000 | Class B | Citation Citation B (HSC 1424) | Patient Rights | $800 | Appealed Closed | 940001406 |
| Corrected Sep 4, 2026 |
| Complaint |
| Aug 11, 2026 | 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 | D · Potential harm Isolated | Corrected Sep 4, 2026 | Complaint |
| Aug 11, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Sep 4, 2026 | Complaint |
| May 28, 2026 | 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 Jun 17, 2026 | Complaint |
| May 7, 2026 | K-0331 | Construct fire resistant interior walls. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 31, 2026 |
| May 7, 2026 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 31, 2026 |
| May 7, 2026 | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 31, 2026 |
| May 7, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 31, 2026 |
| May 7, 2026 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 31, 2026 |
| May 7, 2026 | 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 May 31, 2026 |
| May 7, 2026 | 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 May 31, 2026 |
| May 7, 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 May 31, 2026 |
| May 7, 2026 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 31, 2026 |
| May 7, 2026 | 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 | D · Potential harm Isolated | Corrected May 31, 2026 |
| May 7, 2026 | F-0605 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 31, 2026 |
| May 7, 2026 | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 31, 2026 |
| May 7, 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 May 31, 2026 |
| May 7, 2026 | 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 May 31, 2026 |
| May 7, 2026 | 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 May 31, 2026 |
| May 7, 2026 | 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 | D · Potential harm Isolated | Corrected May 31, 2026 |
| May 7, 2026 | 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 May 31, 2026 |
| May 7, 2026 | 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 | D · Potential harm Isolated | Corrected May 31, 2026 |
| May 7, 2026 | F-0802 | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected May 31, 2026 |
| May 7, 2026 | 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 May 31, 2026 |
| May 7, 2026 | F-0813 | Have a policy regarding use and storage of foods brought to residents by family and other visitors. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected May 31, 2026 |
| May 7, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected May 31, 2026 |
| May 7, 2026 | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 31, 2026 | Complaint |
| May 7, 2026 | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 31, 2026 | Complaint |
| May 7, 2026 | E-0041 | Implement emergency and standby power systems. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected May 31, 2026 |
| Mar 13, 2026 | 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 31, 2026 | Complaint |
| Mar 13, 2026 | 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 Mar 31, 2026 | Complaint |
| Mar 13, 2026 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 31, 2026 | Complaint |
| Jan 30, 2026 | 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 Feb 19, 2026 | Complaint |
| Dec 17, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Jan 12, 2026 | Complaint |
| Dec 12, 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 Dec 22, 2025 | Complaint |
| Dec 12, 2025 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 22, 2025 | Complaint |
| Jul 2, 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 22, 2025 | Complaint |
| Jul 2, 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 Jul 22, 2025 | Complaint |
| Mar 14, 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 Apr 4, 2025 |
| Mar 14, 2025 | K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 4, 2025 |
| Mar 14, 2025 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 4, 2025 |
| Mar 14, 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 | E · Potential harm Pattern | Corrected Apr 7, 2025 |
| Mar 14, 2025 | F-0553 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 7, 2025 |
| Mar 14, 2025 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Apr 7, 2025 |
| Mar 14, 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 Apr 7, 2025 |
| Mar 14, 2025 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Apr 7, 2025 |
| Mar 14, 2025 | 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 Apr 7, 2025 |
| Mar 14, 2025 | F-0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Apr 7, 2025 |
| Mar 14, 2025 | 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 | E · Potential harm Pattern | Corrected Apr 7, 2025 | Complaint |
| Mar 14, 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 | E · Potential harm Pattern | Corrected Apr 7, 2025 | Complaint |
| Mar 14, 2025 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Apr 7, 2025 | Complaint |
| Mar 14, 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 | E · Potential harm Pattern | Corrected Apr 7, 2025 |
| Mar 14, 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 Apr 7, 2025 |
| Mar 14, 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 Apr 7, 2025 |
| Mar 14, 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 Apr 7, 2025 |
| Mar 14, 2025 | 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 Apr 7, 2025 |
| Mar 14, 2025 | F-0691 | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 7, 2025 |
| Mar 14, 2025 | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Apr 7, 2025 |
| Mar 14, 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 | E · Potential harm Pattern | Corrected Apr 7, 2025 |
| Mar 14, 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 | D · Potential harm Isolated | Corrected Apr 7, 2025 |
| Mar 14, 2025 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Apr 7, 2025 |
| Mar 14, 2025 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Apr 7, 2025 |
| Mar 14, 2025 | 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 Apr 7, 2025 |
| Mar 14, 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 Apr 7, 2025 |
| Mar 14, 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 Apr 7, 2025 |
| Mar 14, 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 | F · Potential harm Widespread | Corrected Apr 7, 2025 |
| Mar 14, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Apr 7, 2025 | Complaint |
| Mar 14, 2025 | F-0881 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Apr 7, 2025 |
| Mar 14, 2025 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Apr 7, 2025 |
| Mar 14, 2025 | F-0887 | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Apr 7, 2025 |
| Mar 14, 2025 | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 7, 2025 |
| Mar 14, 2025 | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 7, 2025 |
| Jan 30, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Feb 21, 2025 | Complaint |
| Jan 30, 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 Feb 21, 2025 | Complaint |
| Jan 30, 2025 | F-0865 | Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Feb 21, 2025 | Complaint |
| Jan 8, 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 Jan 28, 2025 | Complaint |
| Sep 24, 2024 | 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 | E · Potential harm Pattern | Corrected Oct 16, 2024 | Complaint |
| Sep 5, 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 Oct 2, 2024 | Complaint |
| Sep 5, 2024 | 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 | D · Potential harm Isolated | Corrected Oct 2, 2024 | Complaint |
| Jun 17, 2024 | F-0740 | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jul 5, 2024 | Complaint |
| May 13, 2024 | 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 May 30, 2024 | Complaint |
| Mar 29, 2024 | 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 Apr 19, 2024 | Complaint |
| Mar 29, 2024 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 19, 2024 |
| Mar 29, 2024 | K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 19, 2024 |
| Mar 29, 2024 | K-0331 | Construct fire resistant interior walls. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 19, 2024 |
| Mar 29, 2024 | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 19, 2024 |
| Mar 29, 2024 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 19, 2024 |
| Mar 29, 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 | E · Potential harm Pattern | Corrected Apr 19, 2024 |
| Mar 29, 2024 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 19, 2024 |
| Mar 29, 2024 | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Apr 19, 2024 |
| Mar 29, 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 Apr 19, 2024 |
| Mar 29, 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 | E · Potential harm Pattern | Corrected Apr 19, 2024 |
| Mar 29, 2024 | 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 Apr 19, 2024 |
| Mar 29, 2024 | 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 Apr 19, 2024 |
| Mar 29, 2024 | 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 Apr 19, 2024 |
| Mar 29, 2024 | F-0802 | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Apr 19, 2024 |
| Mar 29, 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 | E · Potential harm Pattern | Corrected Apr 19, 2024 |
| Mar 29, 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 Apr 19, 2024 |
| Mar 29, 2024 | F-0814 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Apr 19, 2024 |
| Mar 29, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Apr 19, 2024 |
| Mar 29, 2024 | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 19, 2024 |
| Jan 26, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Feb 14, 2024 | Complaint |
| Jan 10, 2024 | 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 Feb 1, 2024 | Complaint |
| Dec 4, 2023 | F-0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 22, 2023 | Complaint |
| Nov 28, 2023 | 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 Dec 22, 2023 | Complaint |
| Nov 28, 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 Dec 22, 2023 | Complaint |
| Nov 21, 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 Dec 18, 2023 | Complaint |
| Nov 8, 2023 | 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 Dec 7, 2023 | Complaint |
| Nov 8, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Dec 7, 2023 | Complaint |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.00 (case-mix index 1.54).
| Dec 24, 2008 |
| Hung Manh Nguyen | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Mar 13, 2017 |
| 1-Call Staffing Services | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Dec 16, 1999 |
| Twomagnets LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Dec 16, 1999 |
| James Morrison | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Dec 24, 2008 |
| Hung Manh Nguyen | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 13, 2017 |
| Soon Burnam | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jan 30, 2006 |
| Chad Keetch | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Mar 1, 2011 |
| Adam Willits | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jan 1, 2023 |
| Caretrust Gp LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Dec 16, 1999 |
| Caretrust Reit Inc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Dec 16, 1999 |
| Ctr Partnership LP | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Dec 16, 1999 |
| Ensign Services Inc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Aug 1, 2002 |
| Southland Management, LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Dec 16, 1999 |
| Soon Burnam | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jul 11, 2025 |
| James Morrison | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jul 11, 2025 |
| Hung Manh Nguyen | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jul 21, 2025 |
| 74 |
| Jan 15, 2026 |
68 |
| — |
| Grand Terrace Health Care Center 12000 Mount Vernon Ave, Grand Terrace, CA 92313 CCN 0551291 state class AA/A | 59 | Mar 5, 2026 | 38 | — |
| Madera Post Acute Center 11900 Ramona Boulevard, El Monte, CA 91732 CCN 0551419 state class AA/A | 148 | Aug 3, 2026 | 741 IJ1 harm | $30k |
| Lemon Grove Care and Rehabilitation Center 8351 Broadway, Lemon Grove, CA 91945 CCN 0551822 state class AA/A | 158 | Dec 18, 2025 | 63 | — |
| Garden View Post Acute Rehabilitation 14475 Garden View Lane, Baldwin Park, CA 91706 CCN 0551872 state class AA/A | 97 | May 7, 2026 | 53 | — |
| Victoria Healthcare and Rehabilitation Center 340 Victoria Street, Costa Mesa, CA 92627 CCN 0552371 state class AA/A | 79 | Aug 14, 2026 | 38 | — |
| Fairmont Rehabilitation Hospital 950 S. Fairmont Avenue, Lodi, CA 95240 CCN 0552422 state class AA/A | 59 | May 7, 2026 | 52 | — |