White Memorial Medical Ctr DP
1720 Cesar E. Chavez Avenue, Los Angeles, CA 90033 · Non profit - Church related · 27 certified beds · (323) 268-5000 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- it did not file the payroll staffing data CMS requires — its 1 of 5 staffing rating is the rating CMS assigns for not reporting, not a measure of how many nurses are on the floor
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | Not rated |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 measures | Not 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 fell from 5 to 3 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.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
68.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 77 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 68.4%CMS range 56.7–77.6 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 7.4–14.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.0%CMS range 5.3–15.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.77 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.
Inspection trend
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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
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.
18 citations, most serious first. The 10 most serious are shown; the remaining 8 are one tap away and print in full.
- Potential for harm · Ecited before2024-05-19 · tag F0578 — failed to honor advance directives / code status — patternHonor 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.
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 three (3) of four (4) sampled Residents (Residents 4, 60, and 111) and/or the Residents' representatives were informed and provided written information regarding the right to formulate an advance directive (a written statement of a resident's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the resident be unable to communicate them to the doctor). This deficient practice had the potential for Residents 4, 60, and 111 and/or residents' representative to not know their rights and cause conflict in carrying out the Residents wishes for medical treatment and health care decisions. Findings: 1. A record review of Resident 4's Face Sheet (FS) indicated the resident was admitted to the facility on [DATE]. The FS indicated Family Member 1 was Resident 4's responsible party. A record review of Resident 4's History and Physical (H&P), dated 4/15/2024, indicated Resident 4 had diagnoses…
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.
- Potential for harm · Ecited before2024-05-19 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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 ensure safe and sanitary conditions were maintained in the kitchen as indicated on the facility policy when: 1. Dietary Aid 1 (DA 1) and Dietary Aid 2 (DA 2), observed with a beard, did not have a beard cover, while in the kitchen food preparation area. 2. An opened bottle of browning and seasoning sauce and a 60 ounce (oz, unit of mass, weight or volume) container of crushed pepper was observed unlabeled and undated. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness (food poisoning with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) which could lead to other serious medical complications and hospitalization. Findings: 1. During an observation in the facility kitchen, on 5/19/2024 at 11:44 AM, Dietary [NAME] 2 (DA 2), who had visible beard, was observed scooping rice from one tray to another. DA 2 did not have a beard cover on. During an observation…
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.
- Potential for harm · E2024-05-19 · tag F0887 — patternEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
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 offer five (5) of 5 sampled residents (Residents 4, 60, 61, 62, and 110) the Covid-19 (a respiratory viral infection that affects primarily the lungs and result in cough and difficulty breathing) vaccine (substance used to stimulate immunity to particular infectious disease) and failed to provide a documented evidence that the resident or their the resident's responsible party (RP) were provided education regarding the benefits and potential risks associated with COVID-19 vaccine. This deficient practice had the potential to expose the residents of the facility to Covid-19 infection. Findings: 1. A record review of Resident 4's Face Sheet, indicated the resident was admitted to the facility on [DATE] with a diagnosis of right foot osteomyelitis (inflammation of bone caused by infection). A record review of Resident 4's History and Physical (H&P), dated 4/15/2024, indicated Resident 4 had diagnoses that included diabetes (elevated blood sugar),…
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.
- Potential for harm · Dcited before2024-05-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 prevent the development of a pressure ulcer (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for one of one sampled resident (Resident 60) by leaving the resident in chair without a pressure relieving device for five hours and 30 minutes in accordance with the facility policy. This deficient practice had the potential for Resident 60 to develop pressure ulcer. Findings: A review of Resident 60's Face sheet, indicated the facility admitted the resident on 5/7/2024. A review of Resident 60's History and Physical (H&P), dated 5/6/2024, indicated Resident 60 had diagnoses that included sepsis (bloodstream infection) due to infected central venous catheter and end stage renal dialysis (ESRD, a medical condition in which a resident's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis [procedure to remove metabolic waste products or toxic substances from 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.
- Potential for harm · D2024-05-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 ensure one of one sampled resident (Resident 111) was free from accident hazards in accordance with the facility policy when Resident 111's Family Member 1 (FM1), who was not provided training on how to assist resident with meals was observed giving the resident a drink through a straw while the resident's head of bed was flat. This deficient practice had the potential for Resident 111 to choke (have severe difficulty in breathing because of a constricted or obstructed throat or a lack of air) or aspirate (occurs when contents such as food, drink, saliva or vomit enters the lungs). Findings: A review of Resident 111's Face sheet, indicated the facility admitted the resident on 5/11/2024. A review of Resident 111's History and Physical (H&P), dated 5/11/2024, the H&P indicated Resident 111 had diagnoses that included osteomyelitis (bone infection) of the right ankle and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning.)…
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.
- Potential for harm · E2023-06-18 · tag F0700 — patternTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 assess 8 of 8 sampled residents (Residents 8, 9, 10, 11, 12, 13, 14, and 15) for the risk of entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed and bed rail) from bed rails (adjustable metal or rigid plastic bars that attach to the bed) prior to installation, and failed to ensure safety standards were met prior to installation by ensuring bed dimensions were measured based on the residents' size and weight. This deficient practice placed Residents 8, 9, 10, 11, 12, 13, 14, and 15 at risk for entrapment that could cause serious harm, injury, or death. Findings: 1. A review of Resident 8's Registration Record indicated the facility admitted the resident on 5/16/2023. A review of Resident 8's History & Physical (H&P), dated 5/16/2023, indicated the resident was admitted to the facility with diagnoses that included hypertension (chronic elevated blood pressure), atrial fibrillation…
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.
- Potential for harm · Ecited before2023-06-18 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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 ensure sanitary and clean environment was maintained in the kitchen. During the inspection of the kitchen the following were observed: 1. One open/ripped plastic bag containing garlic bread in the freezer was not labeled and dated when it was opened. 2. One dairy crate had flour tortillas and was labeled as dice chicken. 3. The dishwasher during rinse cycle (clean water as a final stage in washing) did not function since 6/7/2023 and the temperatures were not within normal ranges (were below 180 degrees Fahrenheit). 4. The facility had dairy crates as food storage containers: There were 52 open dairy crates in the walking freezer, on the second freezer there were 120 dairy crates, and inside the dry food storage there were 40 dairy crates. Three crates were touching the floor and no evidence to show how the crates were being cleaned. 5. The plastic strips in the gaskets (the lining that goes around your refrigeration equipment doors to keep air flow accurate) for the refrigerators were torn . These deficient…
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.
- Potential for harm · D2023-06-18 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her 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 observation, interview, and record review, the facility failed to treat one (1) of eight (8) sampled residents (Resident 13) with dignity and respect in accordance with the facility's Privacy and Dignity of Residents policy and procedure. This deficient practice had the potential to result in decreased self-esteem and self-worth of Resident 13. Cross Reference F656 Findings: A review of Resident 13's Registration Record (admission record) indicated the facility admitted Resident 13 on 6/9/2023 with diagnoses of bacteremia (viable bacteria in the blood) nephrolithiasis (kidney stones). A review of Resident 13's Edema (swelling caused due to excess fluid accumulation) care plan dated, 6/8/2023, indicated Resident 13 had the presence of scrotal edema (a type of swelling in the pouch of skin that holds the testicles). The care plan interventions included were for the nursing staff (in general) to keep the area clean and dry at all times. A review of Resident 13's History and Physical (H&P), dated 6/12/2023,…
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.
- Potential for harm · Dcited before2023-06-18 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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.
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 follow its policy on Advanced Directives (written instructionrecognized under State law relating to the provision of health care when the individual is incapacitated [inability to perform regular daily activities because of a serious health condition]) by failing to inform and provide documented notification for 1 of 8 sampled residents (Resident 11) of the right to formulate an advanced directive. This deficient practice had the potential to deny Resident 11 the right to request or refuse medical care and treatment. Findings: A review of Resident 11's Registration Record indicated the facility admitted the resident on 5/26/2023 with an initial diagnosis of right foot gangrene (dead tissue). A review of Resident 11's H&P, dated 5/26/2023, indicated the resident had diagnoses that included Cerebral Vascular Accident (CVA, death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired) with residual left sided weakness, end stage renal disease (ESRD, medical condition in which 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.
- Potential for harm · Dcited before2023-06-18 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 interview, observation, and record review the facility failed to develop and implement an individualized and comprehensive care plan to meet the individual needs for two (2) of 8 sampled residents (Resident 11 and Resident 13) by failing to: 1. Implement interventions outlined in Resident 11's care plan indicating the need to ensure the residents blood glucose (blood sugar found in the blood, which is the body's primary source of energy) levels were maintained within the normal range of 80-100 milligrams (mg)/deciliter (dL, metric unit of capacity). 2. Implement interventions to address Resident 13's scrotal edema (a type of swelling in the pouch of skin that holds the testicles). These deficient practices placed Residents 11 and 13 at risk for lack or delay in delivery of care and services necessary for the residents' overall well being. Cross reference: F550 for Resident 13 Findings 1. A review of Resident 11's Registration Record (admission record) indicated the facility admitted the resident on…
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.
Show the remaining 8 citations
- Potential for harm · D2023-06-18 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
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 develop an activity plan for 1 of 8 sampled residents (Resident 13) that reflected his needs and interests as indicated in the Activity Program Overview policy and procedure. This deficient practice had the potential for Resident 13 to experience boredom. Findings: A review of Resident 13's Registration Record (admission record) indicated the facility admitted Resident 13 on 6/9/2023 with diagnoses of Bacteremia (viable bacteria in the blood) Nephrolithiasis (kidney stones). A review of Resident 13's History and Physical (H&P), dated 6/12/2023, indicated Resident 13 was alert and oriented. A review of Resident 13's Minimum Data Set (MDS, assessment and care screening tool), 6/14/2023, indicated Resident 13 was totally dependent on staff for toileting, dressing, bed transfers, and mobility. During an observation and interview on 6/17/2023, at 7:39 am, inside Resident 13's room, Resident 13 was awake and alert lying in bed. Resident 13 stated he was always in bed and was bored. Resident 13 stated he enjoyed 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.
- Potential for harm · Dcited before2023-06-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 ensure 1 of 1 sampled resident (Resident 13) who was at risk for skin breakdown and pressure injuries (PI, areas of damaged skin caused by staying in one position for too long), had interventions to prevent PIs. This deficient practice had the potential for Resident 13 to develop PIs which could lead to discomfort, hospitalization and death. Findings: A review of Resident 13's Registration Record (admission record) indicated the facility admitted Resident 13 on 6/9/2023 with diagnoses of bacteremia (viable bacteria in the blood) and nephrolithiasis (kidney stones). A review of Resident 13's Skin Breakdown/Potential care plan dated 6/8/2023, indicated Resident 13 had the potential for skin breakdown due to incontinence (is the involuntary loss or leakage of urine or feces), and one of the nursing interventions was to provide pressure relieving devices as appropriate. A review of Resident 13's Measurements, dated 6/10/2023, timed at 12:30 pm, indicated Resident 13 weighed 88.8 kilograms (kg, a unit of mass). 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.
- Potential for harm · D2023-06-18 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
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 ensure the intravenous (IV, is a therapy that delivers liquid substances directly into a vein) tubing was labeled for 1 of 1 sampled resident (Resident 15) as indicated in the facility's Intravenous Therapy, Peripheral Site Maintenance Policy and Procedure. This deficient practice placed Resident 15 at risk for IV complications. Findings: A review of Resident 15's Registration Record (admission record) indicated the facility admitted the resident on 6/15/2023 with diagnosis of metabolic acidosis (too much acid in the blood). A review of Resident 15's Peripheral Line care plan, dated 6/14/2023, indicated Resident 15 would not have infection at the site and one of the nursing interventions was to monitor Resident 15's site every shift for signs and symptoms of infection. A review of Resident 15's History and Physical (H&P), dated 6/17/2023, indicated Resident 15 was alert and oriented. During an observation and interview on 6/18/2023 at 8:16 am, inside Resident 15's room, Resident 15 was alert and awake lying…
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.
- Potential for harm · Dcited before2020-01-09 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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
Based on interview and record review, the facility failed to develop a plan of care for two of ten sampled residents (Resident 3 and 55) as indicated in the facility's policy and procedure. a. For Resident 3, the facility failed to develop a specific plan of care for the use of chlordiazepoxide (a prescription medicine used to treat certain anxiety disorders and symptoms of alcohol withdrawal). b. For Resident 55, the facility failed to develop an individualized care plan for the use of Meropenem (an antibiotic that used to treat severe infections of the skin or stomach). These deficient practices had the potential for the residents not to adequate receive nursing interventions and not to meet their goals. Findings: a. A review of Resident 3's Physician Face Sheet (admission record) indicated the facility admitted the resident on 12/20/19 , with a diagnosis of left middle cerebral artery infarct (MCA, an interruption of blood flow to the areas of the brain that receive blood through the middle cerebral artery). A review of Resident 3's Transfer/Discharge Medication Review and Order…
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.
- Potential for harm · D2020-01-09 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
Based on interview and record review, the facility failed to ensure one of ten sampled residents (Resident 56) received treatment to apply dressing to surgical wound site after shower as per physician's order. This deficient practice had a potential for lack of care and treatment on the surgical wound. Findings: A review of Resident 56's Physician Face Sheet indicated, the facility admitted Resident 56 on 1/3/20, with a diagnosis of gastrointestinal bleed (GI bleed is when bleeding occurs in any part of the gastrointestinal tract includes esophagus, stomach, small intestine, large intestine (colon), rectum, and anus). A review of Resident 56's History and Physical dated 1/4/19, indicated Resident 56's speech was clear and cognition was coherent. A review of Resident 56's Active Order form indicated a physician order dated 1/3/20, the nurse to apply island dressing (consist of a sterile non-woven adhesive backing with an absorbent wound pad which provides a waterproof and bacterial barrier, as an absorbent pad it absorbs light levels of blood or exudate [exudate is a liquid produced…
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.
- Potential for harm · D2020-01-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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
Based on observation, interview, and record review, the facility failed to monitor the behaviors and side effects for one of ten sampled residents (Resident 3) for the use of psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication as indicated in the physician orders. This deficient practice had the potential for inadequate monitoring for effectiveness and adverse consequences of the medication. Findings: A review of Resident 3's Physician Face Sheet (admission record) indicated the facility admitted the resident on 12/20/19, with a diagnosis of left middle cerebral artery infarct (MCA, an interruption of blood flow to the areas of the brain that receives blood through the middle cerebral artery). A review of Resident 3's Transfer/Discharge Medication Review and Order Sheet dated 1/6/20, indicated for the resident was to receive chlordiazepoxide (Librium, a prescription medicine used to treat certain anxiety disorders and symptoms of alcohol withdrawal) 25 milligrams (mg, a unit of measurement) one capsule twice a day. The Order…
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.
- Potential for harm · D2020-01-09 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure one of ten sampled resident's (Resident 58) Skilled Nursing Dialysis Record form was accurate and complete. This deficient practice had a potential for misinformation and misleading information of the care and treatment of the resident. Findings: A review of Resident 58's Physician Face Sheet indicated, the facility admitted Resident 58 on 12/31/19, with a diagnosis of cardiac arrest (is a sudden loss of blood flow resulting from the failure of the heart to pump effectively, that include loss of consciousness and abnormal or absent breathing). A review of Resident 58's Active Orders dated 1/1/20, indicated a physician's order for hemodialysis (a therapy that uses a machine that filters wastes, salts and fluid from the blood, to help control blood pressure and balance important minerals in the body). A review of Resident 58's Active Orders dated 1/1/20 indicated an order for Epogen (a man-made form of a protein that helps your body produce red blood cells used to treat anemia [a lack of red blood cells in the body]),…
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.
- No harm found · B2020-01-09 · tag F0623 — patternProvide 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 provide to two of ten sampled residents (Resident 4 and 6) and their Family Member (FM), a written notice of proposed discharge prior to the residents discharge. Resident 4's written notice of proposed discharge had not been completed. This deficient practice had the potential for Resident 4 and 6 and their FM not have an opportunity to exercise their rights to appeal if they believe that the discharge was inappropriate. Findings: a. A review of Resident 4's Physician Face Sheet (admission record) indicated, the facility admitted Resident 4 on 12/22/19, with a diagnosis of gangrene (refers to the death of body tissue due to either a lack of blood flow or a serious bacterial infection) of left big toe. The Face Sheet indicated Resident 4 was discharged on 1/2/20. A review of Resident 4's Minimum Data Set (MDS - standardized assessment and care planning tool) dated 1/2/20 indicated, Resident 4's cognition (perception, thought, memory, and ways 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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to ADVENTIST HEALTH — 5 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 4.0 | -1.0 vs chain |
| Health inspection | 4 of 5 | 3.8 | +0.2 vs chain |
| Staffing | 1 of 5 | 3.6 | -2.6 vs chain |
The other 4 homes this chain runs (chain average 4.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| OWENS, FRANCIS | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | since 09/15/2022 |
| RAFFOUL, JOHN | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | since 06/08/2010 |
| BECKETT, ANN | Individual | CORPORATE DIRECTOR | since 01/01/2024 |
| CHERRY, ROBERT | Individual | CORPORATE DIRECTOR | since 05/05/2017 |
| DAGGETT, JONATHAN | Individual | CORPORATE DIRECTOR | since 01/01/2024 |
| DAVIS, ANDREW | Individual | CORPORATE DIRECTOR | since 05/05/2017 |
| FEHR, JOY | Individual | CORPORATE DIRECTOR | since 10/01/2020 |
| FREEDMAN, JOHN | Individual | CORPORATE DIRECTOR | since 09/26/2016 |
| HEINRICH, KERRY | Individual | CORPORATE DIRECTOR | since 06/01/2015 |
| HOFHEINS, TODD | Individual | CORPORATE DIRECTOR | since 01/24/2022 |
| INNOCENT, LARRY | Individual | CORPORATE DIRECTOR | since 09/09/2011 |
| JUTZY, KENNETH | Individual | CORPORATE DIRECTOR | since 01/01/2024 |
| NEWTON, BRADFORD | Individual | CORPORATE DIRECTOR | since 08/16/2021 |
| REINER, RICHARD | Individual | CORPORATE DIRECTOR | since 01/16/2017 |
| SALAZAR, VELINO | Individual | CORPORATE DIRECTOR | since 09/15/2015 |
| WAGNER, JACK | Individual | CORPORATE DIRECTOR | since 12/01/2022 |
| WOODSON, MARC | Individual | CORPORATE DIRECTOR | since 01/01/2019 |
| JOBE, MEREDITH | Individual | CORPORATE OFFICER | since 03/31/2014 |
| ADVENTIST HEALTH SYSTEM/WEST | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 06/16/1980 |
CMS files one row per role, so the 21 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner 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
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.
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 555312. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-05-19, 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.