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Los Angeles Comm Hospital

4081 East Olympic Blvd, Los Angeles, CA 90023 · For profit - Corporation · 39 certified beds · (323) 267-0477 Medicare & Medicaid certified

Call the home — (323) 267-0477 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0605) — most recent Feb 2026Behavioral-health or dementia-care citation — no harm found (F0758)$14,434 in federal fines
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • lower-than-typical staff turnover (21% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,434 in federal fines (most recent 2026-02-06)
  • its payroll-based staffing rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facilityNot rated

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4055 E Olympic Blvd · (323) 268-3491 · Call to confirm hours
Pharmacy
4055 E Olympic Blvd · (323) 262-8230 · Call to confirm hours
Grocery
3980 E Olympic Blvd · (323) 262-0810 · Call to confirm hours
Park
3864 Whittier Blvd · (323) 260-2330 · Typically dawn to dusk
Place of worship
4004 E Olympic Blvd · (323) 406-0190

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measuresNot rated

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents who lose too much weight0.0%4.0%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder14.2%0.8%0.9%worse
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms0.0%7.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained18.4%0.4%0.1%worse than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%1.6%3.3%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication17.0%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers32.6%4.3%4.7%check this — see note marked dagger below the table
Long-stay residents with worsening bladder/bowel control0.0%10.2%21.2%check this — see note marked star below the table
Short-stay residents given the seasonal flu vaccine95.5%93.2%79.4%better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Staffing

1.55
RN hours/ resident / day
2.57
LPN hours/ resident / day
2.49
Aide hours/ resident / day
6.61
Total nurse hours/ resident / day
1.25
RN hoursweekends
20.8%
Total nursing turnover
31.3%
RN turnover

How full it usually is: this home is certified for 39 beds and averages 38.4 residents a day — about 98% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 6.61 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.55 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.49 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 6.04 hrs/resident/day on weekends vs 6.85 on weekdays — 12% thinner on weekends. RN hours go from 1.68 to 1.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 21% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

9
deficiencies at the latest standard inspection (2026-02-06)
11
at the previous standard inspection (2024-11-24)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · Ecited before2026-02-06 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control and Enhanced Barrier Precaution (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes) protocols for two of six residents (Resident 23 and Resident 2), by not wearing the required personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) during suctioning and not maintaining proper infection control practices during wound care.These deficient practices placed Residents 23 and 2 and other residents at increased risk for infection.Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. During a review of Resident 2's History and Physical (H&P), dated 7/30/2025, the H&P indicated Resident 2's diagnoses included a pressure injury (localized damage to the skin…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-06 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of eight sampled residents (Resident 13 and Resident 24) had informed consent prior to the placement of hand and wrist restraints. This deficient practice resulted in Resident 13 and Resident 24 being placed in restraints without consent from their responsible party. Findings: 1. During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE]. During a review of Resident 13's electronic medical records, the electronic medical records indicated Resident 13's diagnoses included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury) and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). During a review of Resident 13's History and Physical (H&P), dated 3/4/2025, the H&P indicated Resident 13 was unable to convey any…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-06 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure as needed (PRN) orders for lorazepam (Ativan, a medication to treat anxiety [feeling of unease]), did not exceed a 14-day administration period for two of 12 sampled residents (Resident 2 and Resident 19). This deficient practice had the potential to result in prolonged administration of lorazepam placing the resident at risk for serious complications such as dependence on the medication, sedation, and withdrawal from prolonged use (the physical and mental symptoms that a person has when they suddenly stop or cut back the use of an addictive substance).Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. During a review of Resident 2's History and Physical (H&P), dated 7/30/2025, the H&P indicated Resident 2's diagnoses included anxiety disorder (excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-06 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a care plan for three of 12 sampled residents (Resident 2, Resident 7, and Resident 14). This deficient practice placed Residents 2, 7, and 14 at risk of not receiving resident-centered interventions.Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. During a review of Resident 2's History and Physical (H&P), dated 7/30/2025, the H&P indicated Resident 2's diagnoses included a pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) and an open wound. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 11/26/2025, the MDS indicated Resident 2 had moderately impaired cognition (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 2 required substantial to maximal assistance from staff to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-06 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff documented and properly assessed bilateral hand edema (swelling caused by an abnormal accumulation of excess fluid trapped in the body's tissues) and documented the scab above a resident's lip for two resident of eight sampled residents (Resident 7 and 14).These deficient practices delayed care for Resident 7 and 14 and placed the residents at risk for complications due to not receiving the necessary care.Findings:a. During an observation on 2/2/2026 at 10:18 a.m. in Resident 7's room, observed Resident 7 lying in bed. Resident 7 had bilateral hand edema. During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE]. During a review of Resident 7's electronic medical record, the electronic medical record indicated Resident 7 had diagnoses that included respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Foley catheter (a flexible indwelling tube inserted through the urethra [a hollow tube that lets urine leave the body] into the bladder to drain urine into a collection bag) drained properly into the collection bag preventing the backflow of urine (when urine flows backward from the bladder to one or both ureters and sometimes to the kidneys) for one of two residents (Resident 20).This deficient practice placed Resident 20 at an increased risk for potential infection, discomfort, obstruction, and decline in health status.Findings:During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was admitted to the facility on [DATE]. Resident 20's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), enlarged prostate (increased in the size of the prostate [a small gland in the male reproductive system]), and seizures (a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the pulse oximetry (device called placed on a finger or earlobe used to measure the oxygen level of the blood) was applied in order to effectively monitor the oxygen saturation level ([O2 sat], a measurement of how much oxygen the blood is carrying as a percentage) for one of eight sampled residents (Resident 24) receiving respiratory services (treatment, management and care of the patient's breathing). This deficient practice placed Resident 24 at high risk of failing to detect hypoxemia (low blood oxygen), and delayed treatment that can rapidly progress to life-threatening complications. Findings: During observations on 2/2/2026 at 10:22 a.m., and 2/4/2026 at 3:40 p.m., in Resident 24's room, observed Resident 24 was not wearing a pulse oximetry probe. The cord of the pulse oximetry was hanging off the bed. During an observation on 2/5/2026 at 11:00 a.m. in Resident 24's room, observed Resident 24 was not wearing a pulse oximetry…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-06 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure orders for hydrocodone-acetaminophen 5-325 (brand name Norco, an opioid medication used to reduce moderate to severe pain) did not exceed seven (7) days for one of twelve sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for complications related to administration of opioid medications, such as constipation, nausea, vomiting, sedation, dizziness, respiratory depression, physical dependence, addiction, and overdose.Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. During a review of Resident 2's History and Physical (H&P), dated 7/30/2025, the H&P indicated Resident 2's diagnoses included a pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) and open wound. During a review of Resident 2's physician orders for the months of October 2025, November 2025, December 2025, and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-11-24 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure Resident 19's peripheral line (a small flexible tube inserted into a vein near the skin surface to administer fluids and medications) to his right forearm dressing was changed every 72 hours (three days) per policy and procedure. 2. Ensure Resident 17's peripheral line to his right-hand dressing was changed every 72 hours per policy and procedure. 3. Ensure the Medication Cart (Cart 1) was cleaned after a sticky liquid medication had spilled onto other medications. These deficient practices of not changing the peripheral lines dressing placed Resident 19 and 17 at risk for infection at the insertion site. In addition, the sticky liquid medication spill had the potential to result in cross-contamination with other medications. Findings: a. During an observation on 11/23/2024 at 9:46 a.m. in Resident 19 room, Resident 19 had a right forearm peripheral line with a dressing dated 11/16/2024. During a review of Resident 19's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-24 · tag F0577 — isolated
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to: 1. Post the report of complaint investigation results by California Department of Public Health ([CDPH] state licensing and certification agency) during the three preceding years in the areas of the facility that are prominent and accessible to the residents, visitors, family members, or resident representative. This deficient practice placed the residents, visitors, family members, or resident representative at risk of not knowing the status of the facility non-compliance outcome results and past performance history. Findings: During a concurrent observation and interview on 11/23/2024 at 1:09 p.m., with the Director of Nursing (DON) at odd nursing station hallway, the DON stated the survey binder posted on the wall included only the last recertification survey conducted by the CDPH last year. The DON stated the facility was visited by the CDPH for a complaint visit last year and this year. The DON stated the complaint investigation results by the CDPH in the past 2 years were not included in the survey…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · D2024-11-24 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an accurate Minimum Data Set ([MDS] - a resident assessment tool) was completed accurately for one of 12 sampled residents (Resident 8) by failing to: 1. Ensure Resident 8's Psychiatric/Mood Disorder under section I (Active Diagnoses) diagnosis of Psychotic Disorder (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) was encoded correctly. This deficient practice resulted in incorrect data transmitted to Center for Medicare and Medicaid Services (CMS) and had the potential to negatively affect Resident 8's plan of care. Findings: During a review of Resident 8's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 8 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 183's diagnoses included chronic respiratory failure (a serious condition that makes it difficult to breathe on your own)…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-24 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Complete and re-submit the Preadmission Screening and Resident Review ([PASRR - a tool to determine if the person had, or was suspected of having a mental illness, intellectual disability, or related condition) Level one (I) screening and refer one of two sampled residents (Resident 8) who had a new diagnosis of psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) to the appropriate state-designated authority for PASRR Level two (II) evaluation and determination. This deficient practice had the potential to result in Resident 8 not receiving specialized services for mental illness. Cross Reference F641. Findings: During a review of Resident 8's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 8 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 183's diagnoses included…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-24 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure one of six sampled residents (Resident 25) had a revised care plan for interventions on the non-behavioral restraint (a device or method used to restrict a patient's movement preventing them from removing medical tubes or lines) flow sheet. This deficient practice of not having a revised care plan for the Non-Behavioral Restraint Flow Sheet had the potential to increase Resident 25's discomfort. Findings: During a review of Resident 25's admission Record (Face Sheet), the Face Sheet indicated Resident 25 was admitted to the facility on [DATE]. Resident 25's initial diagnose was respiratory failure (a serious condition that makes it difficult to breathe on your own). During a review of Resident 25's History and Physical (H&P), dated 1/7/2024, the H&P indicated, Resident 25's diagnoses included seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure one out six sampled residents (Resident 11) hair was shampooed twice a week. The deficient practice had the potential for Resident feeling unkept and not clean. Findings: During a review of Resident 11's admission Record (Face Sheet), the Face Sheet indicated Resident 11 was admitted to the facility on [DATE]. Resident 11's diagnose was chronic respiratory failure (a serious condition that occurs when the lungs can't get enough oxygen into the bloodstream and can't remove enough carbon dioxide). During a review of Resident 11's History and Physical (H&P), dated 1/7/2024, the H&P indicated, Resident 11's diagnoses included sepsis (a life-threatening blood infection), tracheostomy (a surgical procedure that creates an opening in the neck and inserts a tube into the windpipe to help with breathing), and encephalopathy (a group of conditions that cause brain dysfunction). The H&P indicated Resident 11 was unable to give any…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure the corrugated (a flexible tube that delivers oxygen to a patient from an oxygen source, such as a tank or concentrator) oxygen (air) was labeled with a date of change for one of five sampled residents (Resident 183). This deficient practice had the potential to cause respiratory infection for Resident 183. Findings: During a review of Resident 183's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 183 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 183's diagnoses included chronic respiratory failure (a serious condition that makes it difficult to breathe on your own) with tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help a person to breathe) and gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-24 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure a pharmacy consultant (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) recommendation to review and provide justification for restarting of Quetiapine (a psychotropic drug - any drug that affects brain activities associated with mental process and behavior) for one of out of five sampled residents (Resident 8) was acknowledged and acted upon. This deficient practice for failing to respond to recommendation from the pharmacy consultant placed Resident 8 at risk for unnecessary medication administration. Cross Reference F758. Findings: During a review of Resident 8's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 8 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 183's diagnoses included chronic respiratory failure (a serious condition that makes it difficult to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-24 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure there were consistent indication and behavior was specifically identified and non-pharmacological interventions were attempted to support the use of Quetiapine (a psychotropic drug - any drug that affects brain activities associated with mental process and behavior) for one of five sampled residents (Resident 8). This deficient practice had the potential to develop an undesired effect due to unnecessary psychotropic drug use for Resident 8. Findings: During a review of Resident 8's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 8 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 183's diagnoses included chronic respiratory failure (a serious condition that makes it difficult to breathe on your own) with tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help a person to breathe) and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-24 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to: 1. Ensure the medication error rate was less than 5%. This deficient practice resulted in medication errors. Findings: During an observation of 27 medication administration opportunities, on 11/25/2024, at 8:15 a.m., 2 routine medications out of 27 were not administered at its scheduled time. During a concurrent medication administration observation and record review, on 11/25/2024, at 8:19 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated protocol for administering medication was one hour before and one hour after the scheduled time. LVN 1 stated a nebulizer (a device for producing a fine spray of liquid) medication, levalbuterol (a medication used to prevent or relieve the wheezing, shortness of breath, coughing, and chest tightness), was to be administered 7:00 a.m. by the respiratory therapist (a health professional who evaluates and treats patients with breathing or lung disorders) that morning for Resident 27. LVN 1 stated from observation of the Medication Administration Record (MAR- a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-24 · tag F0761 — failed to label and store drugs safely — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to: 1.Ensure an intravenous (fluids given directly into the blood stream) medication, Amikacin (an antibiotic used to treat serious infections that are caused by bacteria), was refrigerated as labeled. This deficient practice had the potential to result in administering an ineffective medication. Findings: During a concurrent observation and interview, on [DATE], at 1:51 p.m., of the intravenous medication cart (IV cart- a medical cart used to store and transport IV supplies and equipment), with Registered Nurse 1 (RN 1), RN 1 stated intravenous medications were stored in the IV cart or refrigerator, if needed. RN 1 observed an IV medication, dextrose (a sterile solution used to provide your body with extra water and carbohydrates) 5% with Amikacin, had a refrigerate label. RN 1 stated the IV medication was scheduled to be given at 9:00 p.m. RN 1 stated the medication should had been refrigerated and not in the IV cart. RN 1 stated the risk of not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-29 · tag F0761 — failed to label and store drugs safely — pattern
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to remove expired insulin (medication used to regulates the amount of glucose in the blood) vials for three of six residents (Residents 25, 27, and 30) receiving insulin. This deficient practice placed the residents at risk for not receiving the proper strength of insulin doses. Findings: During a concurrent observation, interview, and record review on 11/29/2023 at 5:00 p.m., with the Director of the Sub-Acute unit, in Medication Cart 4 there were three vials of expired insulin. The three insulin vials expired more than 28 days ago. The insulin vials included: 1. Glargine (medication used to reduced blood sugar level) had labeled opened date 10/31/2023 and expiration date of 11/28/2023. 2. Lispro (medication used to reduced blood sugar) had labeled opened date 10/31/2023 and an expiration date on 11/28/2023. 3. Lispro labeled opened date 10/26/2023 and an expiration date on 11/23/2023. The Director of the Sub-Acute unit stated once an insulin vial was opened the opened and expired dates were placed on the vial.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-29 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to communicate with one of six sampled residents' (Resident 12) representative that Resident 12 was transferred to General Acute Care Hospital (GACH) intensive care unit (residents who are dangerously ill are kept under constant observation) due to labored breathing. This failure had the potential to result in Resident 12's representative being unaware of the residents' medical condition and status. Findings: During a review of Resident 12's admission Record (Face Sheet), the Face Sheet indicated Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE]. Record indicated Resident 12's emergency contact was Family Member 1. During a review of Resident 12's History and Physical (H&P), dated 7/30/2023, the H&P indicated Resident 12's diagnoses included respiratory failure (when blood does not have enough oxygen), intracerebral brain hemorrhage ([ICH] bleeding in the brain), seizure disorder (a sudden, uncontrolled burst of electrical…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-29 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to clarify the physician order for the administration route of Pioglitazone (medication to treat high blood sugar levels) for one of seven sampled residents (Resident 27). This failure placed Resident 27 at risk for aspiration due to inability to swallow medications. Findings: During a review of Resident 27's admission Record (face sheet), the face sheet indicated Resident 27 was admitted to the sub-acute on 8/25/2023. Resident 27 ' s diagnoses included hypertension (the pressure in the blood vessels is too high) metabolic syndrome (a cluster of conditions that increase the risk of heart disease), respiratory failure (the blood does not have enough oxygen), tracheostomy (an incision to relieve an obstruction to breathing). During a review of Resident 27's History and Physical (H&P), dated 8/25/2023, the H&P indicated, Resident 27 was alert and oriented and able to verbalize wishes. During a review of Resident 27's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 8/29/2023, the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-29 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 2 performed hand hygiene during a wound dressing change for one of four Residents (Resident 19). This deficient practice placed Resident 19 at increased risk of contamination of the sacral (near the lower back and spine) wound during a dressing change. Findings: During a review of Resident 19's admission Record (Face Sheet), the Face Sheet indicated Resident 19 was admitted to the facility on [DATE]. During a review of Resident 19's History and Physical (H&P), dated 7/12/2023, the H&P indicated Resident 19's diagnoses included respiratory failure (when blood does not have enough oxygen), sepsis (the body's extreme response to an infection). The H&P indicated Resident 19 was clinically quadriplegic (not able to move all for extremities). During a review of Resident 19's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 8/29/2023, the MDS indicated Resident 19's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2026-02-06 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to meet the required room size measurement of 80 square feet ([sq. ft.]- a unit of measurement) of room space per resident in one room with multiple residents.This deficient practice had the potential to compromise resident privacy and could potentially affect residents' health and safety.Findings:During a review of the facility's Client accommodations Analysis Form, dated 2/2/2026, the form indicated one room did not meet the 80 square (sq.) foot (ft.) per resident requirement.During a review of the facility's Room Waiver Request Letter, dated 10/10/2025, the letter indicated room [ROOM NUMBER] did not meet the 80 sq. ft. of space per resident requirement. The letter indicated the facility would ensure not to admit ventilator dependent residents (resident who cannot breathe adequately on their own and require long-term, daily, or continuous mechanical support to assist or control their breathing) in that room. The letter indicated if a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2024-11-24 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to meet a minimum of 80 square feet (sq. ft.) per resident in one room (room [ROOM NUMBER]). This failure to provide adequate space created the potential for adversely affecting the quality of life, safety, health, and the provision of care of residents who may had occupied room [ROOM NUMBER]. Findings: During the entrance conference, on 11/23/2024 at 9:13 a.m., the facility's Director of Nursing (DON) stated the facility had requested and submitted a room waiver for a room variance. The DON provided a copy of room waiver request letter to continue with the waiver request, dated 9/27/2024, indicating room [ROOM NUMBER] (one room with an approved capacity of 2), totaled in size of 157 square feet while the required room size was 160 square feet per room. During an observation, on 11/25/2024, at 2:55 p.m., with the Director of Nursing and the Maintenance Supervisor (MS), the MS measured room [ROOM NUMBER]. The MS indicated the actual square…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Waiver has been granted
  • No harm found · Bcited before2023-11-29 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of one resident rooms (Rooms # 16) met the requirements of 80 square feet (sq. ft.) for each resident. This deficient practice had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents. Findings: During a record review on 11/27/23 at 9:44 a.m., the Administrator (ADM) provided a copy of the facilities annual request for waiver letter. A review of the letter indicated there are 12 resident room with less than the required 80 sq. ft. per resident, and the rooms are monitored to ensure that furnishing and equipment in the room does not hamper provision of needed care and there is sufficient space to meet the needs of both residents. ADM stated the facility would be requesting a room waiver for 2024. According to the Client Accommodations Analysis form, dated 12/13/2016, the facility had room [ROOM NUMBER] that measured less than 199 sq. ft. per resident. However the accurate room…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Waiver has been granted

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$14,434 in federal fines across 2 penalties.

  • $12,670 — penalty dated 2026-02-06
  • $1,764 — penalty dated 2023-08-21

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
ALTA HOSPITALS SYSTEM LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 06/05/2007
CHAMBER INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 06/01/2021
DAVID & ALEXA TOPPER FAMILY TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/15/2010
IVY HOLDINGS INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/15/2010
IVY INTERMEDIATE HOLDING INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/15/2010
MPT OF BELLFLOWER PMH, L.P.Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/23/2019
MPT OF LOS ANGELES PMH, L.P.Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/23/2019
MPT OF NORWALK PMH, L.P.Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/23/2019
PROSPECT MEDICAL HOLDINGS INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/08/2007
LEE, SANG BUMIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICERNO PERCENTAGE PROVIDEDsince 08/08/2007
JP MORGAN CHASE, N.A.Organization5% OR GREATER SECURITY INTERESTsince 06/30/2016
HERNANDEZ, HECTORIndividualW-2 MANAGING EMPLOYEEsince 05/23/2016
JAMES, CARMELOIndividualW-2 MANAGING EMPLOYEEsince 09/15/2016
TOPPER, DAVIDIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 08/08/2007
ELDERS, ROBERTIndividualCORPORATE OFFICERsince 06/15/2020
GORENSTEIN, WILLIAMIndividualCORPORATE OFFICERsince 08/15/2016
JOHNSON, MARKIndividualCORPORATE OFFICERsince 07/27/2020
SABILLO, ALFREDOIndividualCORPORATE OFFICERsince 07/21/2020
SAMUELS, ERICIndividualCORPORATE OFFICERsince 06/03/2019

CMS files one row per role, so the 22 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.

10 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

What families pay in CA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.

Typical monthly cost in California
$12,167/mo
Nursing home (semi-private)
$15,178/mo
Nursing home (private)
$7,000/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555638. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-06, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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