Home / California / Garden Grove
12232 Chapman Ave, Garden Grove, CA 92840 · Orange County · (714) 971-5517
99 certified beds, about 91 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1967
CMS Care Compare ratings, data as of September 1, 2026 · CCN 055816 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on January 21, 2026, inspectors cited 21 health deficiencies (the California average is 15.6, the national average 9.2).
None of its 58 health citations since May 2022 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 6.20 hours per resident per day, against 4.52 across California and 3.86 nationally. Registered nurses accounted for 0.70 of those hours.
26.3% of nursing staff left within the year CMS measured (California average 36.7%).
CMS links it to The Mandelbaum Family, an affiliated group of 18 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 58 health citations on file.
Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide the safe and sanitary environment were implemented for two of four sampled residents (Residents 1 and 2). * The facility failed to ensure RN 1 wore the proper PPEs when assessing Resident 1 who had tracheostomy, gastrostomy tube, and history of C-auris. * The facility failed to ensure CNA 1 performed proper hand hygiene and handling of linens when providing care for Resident 2. * The facility failed to ensure the dirty equipment was not touching the clean surfaces when cleaning Room A. These failures posed the risk for transmission of disease-causing microorganisms and infections.
Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure one heavy-duty blender used for puree preparation was air dried and free of water residue prior to storing. * The facility failed to ensure the microwave utilized to warm up the food was in a sanitary condition. These failures had the potential for cross contamination and foodborne illnesses for the residents consuming the food prepared in the facility's kitchen.
Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to ensure the infection control practices were maintained in the facility's laundry room when a facility staff's personal clothing was stored in the clean laundry storage area. * The facility failed to ensure the water management program was established and implemented to include the specific implementation of measures to prevent the growth of Legionella (type of bacteria that is naturally found in [NAME] environments) and other opportunistic pathogens; and a way to monitor the measures the facility had in place. [...]
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to appropriately obtain consent for the psychotherapeutic medication for one of five final sampled residents (Resident 12) reviewed for unnecessary medications. * Resident 12 was self-responsible, however, the facility obtained the informed consent for the use of the amitriptyline HCl (hydrochloride) (an antidepressant medication) from Family Member 1. This failure resulted in the resident not being provided the adequate information and the right to decline consent for a psychotherapeutic medication.
Inspectors wroteBased on observation and interview, the facility failed to ensure two of eight LVNs (LVNs 4 and 5) provided services meeting professional standards. * LVNs 4 and 5 placed their stethoscopes on the residents' abdominal area when auscultating for the residents' GT placement. This failure posed the risk of the residents not receiving appropriate care.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the proper pressure ulcer precautions and interventions were provided for four of four final sampled residents (Residents 4, 11, 37, and 94) reviewed for pressure ulcer. * The facility failed to ensure the LAL mattress settings were consistent with Resident 11, 37, and 94's weights. This failure had the potential for the residents to not benefit from the therapy provided by the LAL mattress.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary GT (delivery of nutrients through a feeding tube directly into the stomach, duodenum (first part of small intestine), or jejunum (middle part of the small intestine) care and services for two of two final sampled resident (Residents 29 and 83) reviewed for enteral feeding care. * The facility failed to ensure Resident 83 was administered the total amount of enteral feeding as ordered by the physician. In addition, the facility failed to ensure physician order for enteral feeding was complete. * The facility failed to ensure the tubing for Resident 29's GT feeding and water flush was not expired. These failures posed the risk for the resident to develop complications related to GT.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of five final sampled residents (Resident 73) reviewed for respiratory care. * The facility failed to ensure Resident 73's nebulizer mask was stored properly. This failure had the potential to affect the respiratory health and well-being of the resident in the facility.
Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure medication error rate was below 5%. * LVN 5 used dissolved Miralax to dissolve and flush Resident 64's medications. * LVN 4 did not administer ascorbic acid to Resident 29 as ordered. * LVN administered multiple drops to Resident 76, however, the physician's order was to instill one drop to each eye. These failures posed the risk of the residents not receiving their medications as prescribed. Also, these failures resulted in medication error rate of 7.41%.
Inspectors wroteBased on observation and interview, the facility failed to ensure medications were stored securely and maintained in a cleanable condition for three of six medication carts. * Medication Cart 1 contained a UTI stat liquid medication without an expiration date. * The Subacute Treatment cart was observed left unlocked and unattended. * Medication Cart 1 had two areas of layered paper tape on a cracked drawer front, creating a non-cleanable surface. These failures had the potential to result in contamination of medications and unauthorized access, which could lead to the medication errors or harm to the residents.
Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary hospice care and services for one of two final sampled residents (Resident 30) reviewed for hospice services. * The facility failed to ensure Hospice A was notified when the medications listed in Hospice A medication list were discontinued for Resident 30. * The facility failed to ensure the complete documentation of the hospice staff visits were available for Resident 30, and if Hospice A staff visited Resident 30 as scheduled in the Hospice A calendar. These failures posed the risk for the delay in communication and provision of the hospice care between the hospice provider and facility.
Inspectors wroteBased on interview and medical record review, the facility failed to provide the required Medicare beneficiary notices to one of three final sampled residents (Resident 12) reviewed for beneficiaries. * Resident 12 did not receive the Medicare beneficiary notice. This failure resulted in the resident not receiving the notice and right to appeal.
Inspectors wroteBased on observation and interview, the facility failed to provide privacy during personal care for one of three final sampled residents (Resident 4) reviewed for privacy. * LVN 2 failed to fully close the privacy curtain while providing care to Resident 4. Resident 4's back was exposed from the waist down during the treatment and the resident's door was wide open. This failure exposed Resident 4's body to public view and had the potential to negatively impact the resident's dignity, self-esteem, and sense of self-worth.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure an accurate MDS assessment was completed for one of two final sampled residents (Resident 67) reviewed for falls. * The facility failed to code in the MDS assessment Resident 67 had a fall. This failure posed the risk for the resident to not have an individualized plan of care based on the resident's specific needs.
Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to comply with the Level II categorical determination requirements of DHCS as part of the PASRR process for one final sampled resident (Resident 6) reviewed for PASRR. * The facility did not accurately complete the Level I screening following a change in status for Resident 6 who was receiving psychotropic medications. This failure had the potential for the resident to not receive appropriate care and services due to their mental disorder or intellectual disability not being properly identified and evaluated.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure accurate PASARR Level I screening for one of one final sampled resident (Resident 6) reviewed for PASARR.* Resident 6's PASARR Level 1 screening showed the resident had no serious mental illness, however, Resident 6 was prescribed psychotropic medications. This failure had the potential to prevent appropriate evaluation and services rendered for the residents who had serious mental illness.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to address the falls for two of two final sampled residents (Residents 30 and 67) reviewed for falls. * The facility failed to ensure the post fall neurological checks were completed for the full 72 hours, as ordered by the physician for Residents 30 and 67. This failure had the potential for the delay in identifying and intervening post-fall neurological changes.
Inspectors wroteBased on observation and interview, the facility failed to ensure one of four licensed nurses observed possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs. * LVN 5 documented administering the insulin medication to six residents at the same time LVN 5 obtained the residents' blood sugar levels. However, LVN 5 administered the insulin medications at different times from what LVN 5 had documented. This failure posed the risk of the residents not getting appropriate care.
Inspectors wroteBased on observation, interview, medical record review, and review of the facility's P&P, the facility failed to ensure the pharmaceutical services were followed. * The insulin for six of six residents was documented as administered at the same time the blood sugar checks were obtained. This failure posed the risk of not knowing exactly when the insulin was administered. * LVN 5 used dissolved Miralax (laxative) powder to flush the medications * Resident 64's lacosomide (anticonvulsant medication) and dissolved Miralax powder were administered together into Resident 64's GT and did not mix the two medications These failures posed the risk of causing discomfort to Resident 64.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were accurate for one of 18 final sampled resident (Resident 35). * The facility failed to maintain accurate clinical records and monitor significant weight changes for Resident 35. This failure resulted in inaccurate clinical records and lack of timely interventions for significant weight changes, placing the resident at risk for malnutrition and dehydration.
Inspectors wroteBased on interview and medical record review, the facility failed to ensure the facility's Arbitration Agreement was presented to the resident in their preferred language for one of three sampled residents (Resident 12) reviewed for Arbitration. * Resident 12 was presented with an Arbitration agreement in English which was not the resident's primary or preferred language. This failure had the potential for the resident to not understand the Arbitration Agreement thoroughly before they signed the agreement.
Inspectors wroteBased on interview and facility document review, the facility failed to implement their QAPI plan and their past Recertification Survey POC for F759. * The facility failed to ensure the Pharmacy Nurse Consultant conducted medication pass observations for licensed nurses as per facility's QAPI plan. This failure had the potential for ongoing non-compliance and incomplete data being reviewed by the QAPI committee.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment to help prevent the development and transmission of diseases and infections for one sampled resident (Resident 8) observed for infection control practices. * The facility failed to ensure CNA 1 donned the appropriate PPE when providing care to Resident 8 with a physician's order for EBP. This failure posed the risk of transmission of infections to the residents throughout the facility.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop a care plan problem for one sampled resident (Resident 8) who was placed on the EBP due to the presence of a GT. This failure placed the resident at risk to not receive the appropriate interventions needed for GT care and EBP status.
Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * The facility failed to ensure four blenders were not stored wet. * The facility failed to ensure a red cutting board had cleanable surface. * The facility failed to ensure the ice machine was maintained in a sanitary condition. * The facility failed to ensure safe storage of the food brought in by the family. These failures had the potential to result in foodborne illnesses for residents receiving kitchen services.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 343) was safe to self-administer a medication. * Resident 343 had self-administered the lidocaine 5% cream (local anesthetic used to temporarily numb and relieve pain) and kept it at the bedside. Howevever, there was no physician's order for the lidocaine cream and self administration. Resident 343 was not a candidate for self-administer the medications as per the assessment. This failure had the potential for Resident 343 to administer the medication inaccurately.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs for one of 18 final sampled residents (Resident 339) and one nonsampled resident (Resident 45). * The facility failed to ensure the call light was within reach and accessible for Residents 45 and 339. This failure had the potential to negatively impact the residents' psychosocial well-being or result in a delay to receive care.
Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure one of 18 final sampled residents (Residents 55) was referred to PASRR level II review when Resident 55's diagnosis was changed from Alzheimer's with psychosis to schizoaffective disorder. This failure had the potential for Resident 55 to not receive the specialized care and services appropriate for her condition.
Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of two residents (final sampled resident, Resident 26) reviewed for nutrition received the appropriate services needed to maintain acceptable parameters of nutritional status when: * The facility failed to ensure the RD recommendations on 9/26/24, were followed-up with the physician and addressed in the IDT weight variance meeting when Resident 26 had severe weight loss of 11 lbs in 20 days. This failure had the potential for Resident 26 not to receive the necessary intervention to prevent further weight loss.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure necessary care and services related to GT feeding were provided for two of 18 final sampled residents (Residents 18 and 58) reviewed for tube feeding. * The facility failed to ensure Residents 18 and 58 had the updated tube feeding care plans following a revision of tube feeding orders. * The facility failed to ensure Residents 18 and 58's physician's orders for tube feeding had a start time and specified stop time or until dose complete. These failures posed the risk for developing complications related to a GT.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for six of 18 final sampled residents (Residents 51, 58, 70, 76, 339, and 588) and four nonsampled residents (Residents 23, 37, 338, and 340) reviewed for respiratory care. * The facility failed to ensure the oxygen administration to Resident 70 was performed by a licensed nurse and failed to ensure Resident 70's oxygen administration was documented in the MAR. In addition, the facility failed to ensure a No Smoking/Oyxgen in Use sign was posted outside the resident's door per the facility's P&P. * The facility failed to ensure a No Smoking/ Oxygen in Use sign was posted outside the resident's door as per the facility's P&P for Resident 23, 37, 51, 76, and 339. [...]
Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services to attain or maintain the highest physical well-being for one of one final sampled residents (Resident 341) reviewed for hemodialysis care. * The facility failed to ensure the physician's order for Resident 341's dialysis and plan of care addressing Resident 341's hemodialysis care showed the correct location of the permacath site on the right upper chest. This failure had the potential for the delay in Resident 341's dialysis site assessment and resident's poor health outcomes.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 18 final sampled residents (Residents 29 and 339) remained free from accident hazards associated with the use of elevated side rails. * The facility failed to obtain an informed consent and initiate a care plan for the use of the bilateral grab bars for Resident 29. * The facility failed to ensure the least restrictive alternatives were implemented prior to the installation of the grab rails for Resident 339. In addition, the facility failed to ensure the informed consent forms for the use of the grab rails showed who obtained the consent from Resident 339. These failures had the potential to place the residents at risk for an entrapment and serious injury.
Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for one of 18 final sampled residents (Resident 29) and one nonsampled resident (Resident 6). * The Pharmacy Consultant's recommendation for the tramadol (narcotic pain medication) label be changed to show the medication was for pain management and not for severe pain level (7-10) was not followed for Resident 6. * The Pharmacy Consultant's recommendation to have the A1C level monitoring every three months until treatment goal was met, then every six months months, was not followed for Resident 29. These failures had the potential to put Residents 6 and 29 at risk for adverse consequences.
Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of 18 final sampled residents (Resident 29) was free from the unnecessary psychotropic medications. * The facility failed to ensure Resident 29 was monitored for the orthostatic hypotention related to the use of Wellbutrin (a medication used to treat depression), quetiapine (medication used to treat bipolar disorder), and trazodone (a medication used to treat depression). This failure had the potential for the residents to have adverse complications from the psychotropic medications.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate during the medication administration observation was less than five percent (5%). The facility had a cumulative medication error rate of 7.41% when two of 27 opportunities for errors were observed on one licensed nurse (LVN 7) who administered medications to one nonsampled resident (Resident 688). The observed medication administration errors were: * LVN 7 failed to administer the Metamucil 4 in 1 Fiber oral packet (fiber supplement/laxative) medication to Resident 688 as ordered by the physician. * LVN 7 administered 100 mg of enoxaparin sodium (anticoagulant) instead of 10 mg of enoxaparin sodium as ordered by the physician to Resident 688. These failures had the potential to compromise the health and safety of Resident 688.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three residents (Resident 688) observed for medication administration was free from the significant medication errors. * Resident 688 received 100 mg of enoxaparin sodium (anticoagulant medication) instead of 10 mg of enoxaparin sodium as ordered by the physician. This failure posed the risk for adverse consequences to the resident.
Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of medications for three of six medication carts (Medication Carts A, B, and C), one of 18 final sampled residents(Resident 339), and two nonsampled residents (Residents 6 and 338). * The facility failed to ensure Medication Cart A was not left unlocked and unattended. * The facility failed to ensure the IV medications on hold were not stored with the current IV medications in Medication Cart B. [...]
Inspectors wroteBased on observation and interview, the facility failed to ensure one nonsampled resident (Resident 5) was provided with the prescribed therapeutic diet. * The facility failed to ensure Resident 5 was served a meal consistent with the ordered therapeutic diet of mechanical soft, finely chopped diet. Resident 5 was served large pieces of meat with a half piece of hard toast. This failure had the potential for Resident 5's nutritional needs to not be met and aspiration.
Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the facility staff assisted the residents regarding the use and storage of food brought in by the family or visitors for the residents. * The facility failed to ensure the food items in the unlabeled and undated containers on Resident 81's nightstand, and inside a small refrigerator in the resident's room were properly stored. This failure had the potential to cause foodborne illnesses to the medically vulnerable resident population who consume food brought from outside sources.
Inspectors wroteBased on interview, medical record review, and P&P review, the facility failed to ensure the medical records were accurate for one of 18 sampled residents (Resident 29) and one nonsampled resident (Resident 64). * The facility failed to ensure the error on the H&P evaluation form was properly documented for Resident 64 as per the facility's P&P. * The facility failed to ensure the psychotropic medication consent forms for Resident 29 were properly completed by the physician. * The facility failed to ensure the route of medication for Resident 29 was correctly ordered on the MAR. These failures had the potential for the residents' needs not being met as the medical information were incomplete. Findings 1. Review of the facility's P&P titled Documentation Principles revised 2/2018 showed one line or an x should strike out a mistake, which should be initialed and dated. [...]
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of one final sampled residents (Resident 70) reviewed for hospice services. * The facility failed to ensure the Hospice Aide did not provide oxygen to Resident 70 and notified the licensed nurse when Resident 70's oxygen saturation was 80%. In addition, the facility failed to ensure the physician's order on the frequency of the hospice staff visits were carried out, to clarify the frequency of the skilled nursing as needed visits, and to ensure there were no missing skilled nursing and hospice clinical notes. These failures posed the risk for delays in providing Resident 70 immediate care, and delays in the communication between the hospice provider and the facility which may affect the resident care.
Inspectors wroteBased on observation, interview, and facility P&P review , the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to ensure the clean linen cart was covered during the transportation. * The facility failed to ensure the staff performed hand hygiene in between assisting Residents 36 and 50 with meals. * The facility failed to ensure the staff performed hand hygiene before and after wearing gloves during the wound treatment observation for one final sampled resident (Resident 24). These failures had the potential for cross-contamination and spread of infectious organisms in the facility.
Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to conduct the regular bed inspection as part of a regular maintenance program to identify areas of possible entrapment for three of four final sampled residents (Residents 29, 51, and 339) investigated for the side rail use. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.
Inspectors wroteBased on observation, medical record review, and interview, the facility failed to ensure the resident care was provided in a manner to promote dignity and respect for one of 18 final sample residents (Resident 70). * The facility failed to ensure the staff sat next to Resident 70 while assisting the resident to eat. This failure had the potential to negatively impact the resident's feelings of self-worth and well-being.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement the care plan problem addressing fall risk for one of 18 sampled residents (Resident 18). * The facility failed to ensure Resident 18 had the yellow colored ID band to identify a high risk for falls as per the resident's fall care plan. This failure had the potential for not providing necessary care and services to the resident.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services to one of two residents (Resident 48) observed with an indwelling urinary catheter. * The facility failed to ensure the indwelling urinary tubing and catheter bag of Resident 48 was placed below the bladder level. This failure had the potential to cause the resident to develop urinary tract infection.
Inspectors wroteBased on interview and medical record review, the facility failed to provide adequate monitoring of the blood pressure to ensure one of 18 final sampled residents (Resident 341) was free from the unnecessary drugs. * The facility failed to ensure Resident 341's blood pressures were checked prior to administering metoprolol (antihypertensive medication) as prescribed by the physician. This failure had the potential to negatively affect Resident 341's health condition and well-being.
Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the activity staff failed to immediately report to the Charge Nurse when witnessing Family Member 1 hitting Resident 1 on his head with her hand. This failure had the potential to delay the alleged abuse investigation and mandatory reporting requirements.
Inspectors wroteBased on observation, interview, facility document review, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 1) received the correct diet as ordered by the physician. * Resident 1 had a physician's order for a regular diet with no added salt. However, Resident 1 did not receive his meal with no added salt. Resident 1's dietary card, diet order form, [NAME] (form used to document resident information), and food cart log failed to show the correct dietary information in accordance with the physician's order for Resident 1's diet. This failure posed the risk for the resident not receiving food to meet his nutritional needs, which had the potential to lead to nutritional related health complications.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent a fall incident for one of two sampled residents (Resident 1). * Resident 1's shower chair wheels were not locked when arriving at the shower room; therefore, when the resident removed his cover and leaned forward, the shower chair moved and tilted forward, causing the resident to fall on his left knee and sustaining a fracture. This failure had the potential to negatively impact the resident's well-being.
Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by the following: * The facility failed to ensure the storage containers for dry food were completely sealed without noticeable gaps. * The facility failed to ensure the cutting boards were in sanitary condition and with cleanable surface. * The facility failed to ensure the peelers were in sanitary condition and free of food particles. * The facility failed to ensure the kitchen equipment was air dried and free of food particles. * The facility failed to ensure the kitchen utensils were clean and free of food particles. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were not worn out. [...]
Inspectors wroteBased on interview and medical record review, the facility failed to follow up with the regional center's correspondence to enquire if a Preadmission Screening and Resident Review (PASRR) Level II Screening were to be completed to determine specialized services available for one of 18 final sampled residents (Resident 15). This failure had the potential to delay additional services for individualized care and support to enhance their quality of life and to assist them in realizing their full potential, as well as integrating services into the plan of care.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop the individualized resident-centered plans of care for two final sampled residents (Residents 15 and 41). * Residents 15 and 41's care plan interventions were not appropriate for their functional abilities. This failure had the potential for Residents 15 and 41 to not receive adequate and individualized care to support safety and well-being, and not communicate their appropriate plan of care to the interdisciplinary team.
Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 18 final sampled residents (Resident 19) received services consistent with professional standards of practice when: * Resident 19's arm with a dialysis access site was used for taking blood pressures despite a physician's order not to do so. * Resident 19's fluid restriction orders were not followed and the resident's fluid intake logs were inaccurate. These failures had the potential to negatively impact the resident's physical well-being.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure proper accounting and safeguarding of the controlled medications to prevent loss, diversion, or accidental exposure when the incoming and outgoing licensed nurses assigned to Medication Carts A and B were inconsistent with signing the shift count log. This failure posed the risk for loss or diversion of controlled medications.
Inspectors wroteBased on interview and medical record review, the facility failed to ensure the pharmacy consultant's recommendation was acted upon for one of 18 final sampled residents (Resident 15). This had the potential for the resident to be administered a sub-therapeutic medication.
Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner for one of two medications rooms (Medication Room A) and one of eight medication carts (Treatment Cart A). * Eight expired telfa dressings, expired hydrocerin lotion (a moisturizer used to treat or prevent rough, dry skin) and a bag of expired foley catheter leg bag were observed in Treatment Cart A. This failure had the potential for the residents to be exposed to the expired or deteriorated medications or biologicals. * The facility failed to ensure Residents A and B's medications were disposed of at the time of their discharges. This failure had the potential for the medications to be accidentally administered and/or diverted.
11 fire safety citations on file: 1 on January 21, 2026, 2 on December 6, 2024, 8 on May 9, 2022.
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | California | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 6.20 | 4.52 | 3.86 |
| Registered nurses | 0.70 | 0.67 | 0.69 |
| All nursing staff on weekends | 5.65 | 4.09 | 3.42 |
| Nurse aides | 3.25 | ||
| Licensed practical nurses | 2.25 | ||
| Nursing staff turnover (share who left in a year) | 26.3% | 36.7% | 45.8% |
| Registered nurse turnover | 29.4% | 38.1% | 42.9% |
| Administrators who left | 0 |
CMS expects 6.04 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 6.42 on weekdays and 5.65 on weekends, 12% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 6.12 in April to June 2025 to 6.20 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 6.20 | 0.70 | 6.42 | 5.65 | 0.0% | 0 of 90 | 91 |
| Oct to Dec 2025 | 6.18 | 0.75 | 6.43 | 5.55 | 0.0% | 0 of 92 | 92 |
| Jul to Sep 2025 | 6.04 | 0.73 | 6.29 | 5.42 | 0.0% | 0 of 92 | 92 |
| Apr to Jun 2025 | 6.12 | 0.80 | 6.37 | 5.52 | 0.0% | 0 of 91 | 87 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| California, Jan to Mar 2026 | 4.36 | 0.59 | 4.52 | 3.97 | 2.3% | 0.5% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| California, all employers | |||
| CNAs (nursing assistants) | $22.90 | $22.04 to $26.35 | 110,060 |
| LPNs and LVNs | $38.34 | $35.98 to $45.06 | 82,850 |
| Registered nurses | $67.44 | $58.87 to $83.25 | 338,940 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | California | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 12.4 | 10.3 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 2.8 | 0.8 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.2 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.6 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 9.5 | 9.8 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 5.0 | 4.3 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 11.5 | 12.0 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 25.3 | 22.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 9.5 | 11.2 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.8 | 2.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.6 | 1.6 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Chapman Care Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (60.2% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
60.2% this home
Better than the national rate
US median of homes 51.5% · California: 301 better, 190 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 234 eligible stays.
10.5% this home
No different from the national rate
US median of homes 10.7% · California: 10 better, 22 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 245 eligible stays.
8.0% this home
No different from the national rate
US median of homes 7.1% · California: 8 better, 48 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 131 eligible stays.
50.8% this home
Median of homes: California59.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 61 residents counted.
0.0% this home
Median of homes: California0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 160 residents counted.
0.5% this home
Median of homes: California0.6% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 160 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: California96.2% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 9 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: 12232 CHAPMAN AVE, INC.. CMS links this home to The Mandelbaum Family, a group of 18 nursing homes averaging 3.1 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Castro-Garcia, Maria | Corporate director | Individual | 01/01/2023 | |
| Mandelbaum, Janet | Corporate director | Individual | 01/01/2023 | |
| Castro-Garcia, Maria | Corporate officer | Individual | 12/01/2021 | |
| Mandelbaum, Janet | Corporate officer | Individual | 01/02/2019 | |
| Cabatana, Socrates | Operational/managerial control | Individual | 04/16/2007 | |
| Covarruvias, Leticia | Operational/managerial control | Individual | 06/19/2017 | |
| Eister, Gene | Operational/managerial control | Individual | 02/09/2018 | |
| Jordan, Kenneth | Operational/managerial control | Individual | 09/07/2016 | |
| Le, Chinh | Operational/managerial control | Individual | 10/01/2019 | |
| Mandelbaum, Simcha | Operational/managerial control | Individual | 03/01/2026 | |
| Perez, Angelica | Operational/managerial control | Individual | 11/01/2003 | |
| Pham, Julie | Operational/managerial control | Individual | 03/16/2000 | |
| Punsalan, Jena | Operational/managerial control | Individual | 10/09/2023 | |
| Williams, Clinton | Operational/managerial control | Individual | 05/04/2010 | |
| Wooner, Michelle | Operational/managerial control | Individual | 10/09/2023 | |
| Mandelbaum, Brenda | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 04/14/2026 | |
| Hansen | Adp of the SNF | Organization | 01/01/2023 | |
| Joseph Kouri & Christine Kouri Living Trust | Adp of the SNF | Organization | 12/12/2023 | |
| Skillserve Inc | Adp of the SNF | Organization | 01/01/2023 | |
| Cabatana, Socrates | Adp of the SNF | Individual | 04/16/2007 | |
| Castro-Garcia, Maria | Adp of the SNF | Individual | 01/01/2023 | |
| Covarruvias, Leticia | Adp of the SNF | Individual | 06/19/2017 | |
| Eister, Gene | Adp of the SNF | Individual | 02/09/2018 | |
| Jordan, Kenneth | Adp of the SNF | Individual | 09/07/2016 | |
| Le, Chinh | Adp of the SNF | Individual | 10/01/2019 | |
| Mandelbaum, Janet | Adp of the SNF | Individual | 01/01/2023 | |
| Mandelbaum, Simcha | Adp of the SNF | Individual | 03/01/2026 | |
| Perez, Angelica | Adp of the SNF | Individual | 11/01/2003 | |
| Pham, Julie | Adp of the SNF | Individual | 03/16/2000 | |
| Punsalan, Jena | Adp of the SNF | Individual | 10/09/2023 | |
| Williams, Clinton | Adp of the SNF | Individual | 05/04/2010 | |
| Wooner, Michelle | Adp of the SNF | Individual | 10/09/2023 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
Licensed assisted living homes in the same town or within 5 miles, each with its California inspection record.
These are the official offices in California. NursingHomeClear cannot take or act on complaints.