Nursing homeActive
Monrovia Gardens Healthcare Center
615 W. Duarte Rd., Monrovia, CA 91016626358454796 certified beds · 80 residentsFor profit - Limited Liability companyMedicare and Medicaid
Surveys on file
25
since 2023
Deficiencies
100
● 0● 99● 1
Penalties · 3 yrs
—
none on file
Last survey
2026-06-23
Complaint
CMS overall
1 / 5
stars as published by CMS
CMS overall 1/5
Health 1
Staffing 3
Quality 3
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · California Department of Public Health · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-06-23 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2026-06-04 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2026-03-03 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2025-12-19 | Standard | 0150 | CMS-2567 (Care Compare) | — |
| 2025-10-31 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-09-17 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-09-03 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2025-08-27 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-08-05 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2025-07-09 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2025-05-13 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2025-04-24 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2025-03-27 | Complaint | 060 | CMS-2567 (Care Compare) | — |
| 2025-02-26 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2025-02-10 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-01-24 | Complaint | 061 | CMS-2567 (Care Compare) | — |
| 2024-12-31 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-12-24 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2024-11-25 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-10-31 | Standard | 0180 | CMS-2567 (Care Compare) | — |
| 2024-06-21 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-05-29 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-05-09 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2023-10-19 | Standard | 0170 | CMS-2567 (Care Compare) | — |
| 2023-10-11 | Complaint | 010 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · California Department of Public Health publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F552Ensure that residents are fully informed and understand their health status, care and treatments.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-07-13Record 055367-20260623-F552
F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-06-25Record 055367-20260623-F757
F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 055367-20260604-F676
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-03-23Record 055367-20260303-F657
F687Provide appropriate foot care.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-23Record 055367-20260303-F687
F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-23Record 055367-20260303-F698
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-30Record 055367-20251219-F550
F578Honor 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 EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-12-29Record 055367-20251219-F578
F606Not hire anyone with a finding of abuse, neglect, exploitation, or theft.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-29Record 055367-20251219-F606
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-29Record 055367-20251219-F656
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-29Record 055367-20251219-F657
F679Provide activities to meet all resident's needs.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-29Record 055367-20251219-F679
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-12-29Record 055367-20251219-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-29Record 055367-20251219-F686
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-29Record 055367-20251219-F689
F693Ensure 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.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-29Record 055367-20251219-F693
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-29Record 055367-20251219-F695
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-12-29Record 055367-20251219-F755
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-12-29Record 055367-20251219-F812
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-29Record 055367-20251219-F880
F881Implement a program that monitors antibiotic use.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-29Record 055367-20251219-F881
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-11-18Record 055367-20251031-F609
F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-11-23Record 055367-20250917-F557
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-09-23Record 055367-20250903-F558
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-09-24Record 055367-20250903-F677
F808Ensure 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.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-09-23Record 055367-20250903-F808
F908Keep all essential equipment working safely.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-09-15Record 055367-20250827-F908
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-08-27Record 055367-20250805-F558
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-08-30Record 055367-20250805-F677
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-08-21Record 055367-20250805-F867
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-11Record 055367-20250709-F558
F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-27Record 055367-20250709-F604
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-11Record 055367-20250709-F684
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-14Record 055367-20250513-F558
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-14Record 055367-20250513-F607
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-14Record 055367-20250513-F677
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-13Record 055367-20250424-F656
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-04-25Record 055367-20250424-F880
F583Keep residents' personal and medical records private and confidential.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-01Record 055367-20250327-F583
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-01Record 055367-20250327-F677
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-01Record 055367-20250327-F697
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-04-01Record 055367-20250327-F725
F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-28Record 055367-20250327-F806
F807Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-28Record 055367-20250327-F807
F584Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-21Record 055367-20250226-F584
F688Provide 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.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-03-20Record 055367-20250226-F688
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-03-20Record 055367-20250226-F842
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-12Record 055367-20250210-F656
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity GHarm
Care planningFalls
Isolated; actual harm that is not immediate jeopardy.Corrected 2025-02-20Record 055367-20250124-F689
F576Ensure residents have reasonable access to and privacy in their use of communication methods.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-29Record 055367-20250124-F576
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-29Record 055367-20250124-F656
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-02-12Record 055367-20250124-F677
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-20Record 055367-20250124-F684
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-01-27Record 055367-20250124-F725
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-29Record 055367-20250124-F726
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-01-02Record 055367-20241231-F725
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-14Record 055367-20241224-F550
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-26Record 055367-20241224-F684
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-28Record 055367-20241125-F610
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-18Record 055367-20241031-F550
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-31Record 055367-20241031-F558
F578Honor 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 EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-18Record 055367-20241031-F578
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-18Record 055367-20241031-F580
F625Notify 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-20Record 055367-20241031-F625
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 055367-20241031-F641
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-24Record 055367-20241031-F656
F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-18Record 055367-20241031-F676
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-20Record 055367-20241031-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-20Record 055367-20241031-F686
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-20Record 055367-20241031-F690
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-15Record 055367-20241031-F692
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-05Record 055367-20241031-F725
F790Provide routine and 24-hour emergency dental care for each resident.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 055367-20241031-F790
F803Ensure 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 DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-01Record 055367-20241031-F803
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-04Record 055367-20241031-F812
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-15Record 055367-20241031-F880
F919Make sure that a working call system is available in each resident's bathroom and bathing area.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 055367-20241031-F919
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-27Record 055367-20240621-F600
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-02Record 055367-20240529-F580
F688Provide 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.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-15Record 055367-20240509-F688
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-09Record 055367-20240509-F880
F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-05-10Record 055367-20240509-F882
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-14Record 055367-20231019-F550
F645PASARR screening for Mental disorders or Intellectual DisabilitiesScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-14Record 055367-20231019-F645
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-14Record 055367-20231019-F656
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-14Record 055367-20231019-F657
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-14Record 055367-20231019-F658
F685Assist a resident in gaining access to vision and hearing services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-14Record 055367-20231019-F685
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-14Record 055367-20231019-F690
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-14Record 055367-20231019-F692
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-14Record 055367-20231019-F756
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-14Record 055367-20231019-F759
F761Ensure 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.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-14Record 055367-20231019-F761
F770Provide timely, quality laboratory services/tests to meet the needs of residents.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-14Record 055367-20231019-F770
F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-14Record 055367-20231019-F773
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-14Record 055367-20231019-F812
F825Provide or get specialized rehabilitative services as required for a resident.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-14Record 055367-20231019-F825
F837Establish 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.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-14Record 055367-20231019-F837
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-14Record 055367-20231019-F880
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-10-25Record 055367-20231011-F609
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.44
Facility
California
National
California 0.67 · National 0.69
Total nurse hours per resident day4.38
Facility
California
National
California 4.52 · National 3.86
Weekend total nurse hours3.80
Facility
California
National
California 4.09 · National 3.42
Total nursing staff turnover51%
Facility
California
National
California 37% · National 46%
Registered nurse turnover50%
Facility
California
National
California 38% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | California | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 5.2% | 4.3% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 1.5% | 1.6% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 18.7% | 12.0% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 0.4% | 1.2% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.4% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 9.4% | 10.2% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 5.2% | 4.0% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 7.9% | 13.7% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Ag Facilities Operations, LLC Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | — | — |
| Ira E Smedra Living Trust Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 48% | — | — |
| Win Win Enterprises, LLC Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 48% | — | — |
| Balacuit, Donald Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Butenko, Julie Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Cambridge Healthcare Services LLC Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Capela, Heidi Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Cruz, Hayley Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Hassell, Lance Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Lutz, Linda Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Salazar, Paulina Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Smedra, Ira Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Sohal, Jaspal Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Vidales, Miguel Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Wintner, Jacob Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| 615 W. Duarte, LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Balacuit, Donald Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Butenko, Julie Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Cambridge Healthcare Services LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Capela, Heidi Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Hassell, Lance Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Lutz, Linda Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Salazar, Paulina Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Smedra, Ira Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Sohal, Jaspal Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Sohal, Jaspal Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Vidales, Miguel Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Vidales, Miguel Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Win Win Enterprises, LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Wintner, Jacob Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Wintner, Jacob Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
Part of a chain
Cambridge Healthcare Services — 32 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or California.
No county cost figures on file for Los Angeles.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Santa Fe Lodge El Monte | 1.8 mi | 2026-06-30 | 2471 |
| Mayflower Care Center El Monte | 1.8 mi | 2026-05-22 | 0310 |
| Monrovia Post Acute Duarte | 1.8 mi | 2026-06-10 | 0552 |
| Monte Vista Healthcare Center Duarte | 1.9 mi | 2026-06-03 | 0470 |
| The Gardens Of El Monte El Monte | 2.7 mi | 2026-06-24 | 3541 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |