Home / California / Lake Forest
23442 El Toro Road, Lake Forest, CA 92630 · Orange County · (949) 472-0277
52 certified beds, about 40 residents a day · For profit - Partnership · Medicare and Medicaid since 1989
CMS Care Compare ratings, data as of September 1, 2026 · CCN 555391 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on November 26, 2025, inspectors cited 16 health deficiencies (the California average is 15.6, the national average 9.2).
None of its 56 health citations since February 2023 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 5.03 hours per resident per day, against 4.52 across California and 3.86 nationally. Registered nurses accounted for 0.70 of those hours.
35.8% of nursing staff left within the year CMS measured (California average 36.7%).
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 56 health citations on file.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure complete and accurate medical records for one of four sampled residents (Resident 3). * Resident 3's neurological assessments were incomplete. This failures resulted in medical records that contained incomplete or inaccurate information, which could negatively impact the continuity of care.
Inspectors wroteBased on 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 food items inside the refrigerator used for the residents' food brought in from outside sources were properly labeled, discarded after use-by date, and the bins were cleaned. * The facility failed to ensure the ice machine was clean. * The facility failed to ensure the plate conveyor was free of accumulation of dirt. * The facility failed to air-dry the bin containing the scoops. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to determine if it was safe to self-administer the medications left at the bedside for two of twelve final sampled residents (Resident 66 and 68). * Resident 66 had three tablets of Renvela (phosphate binder) in a medication cup at the bedside, and the resident was observed taking the Renvela medications by herself. However, Resident 66 was assessed to not be safe in self-administering medications. In addition, there were no physician's order and a care plan addressing the resident's self-administration of the medication. * Resident 68 was observed with a bottle of nasal spray at bedside. However, Resident 68 was assessed to not be safe in self-administering the medications. [...]
Inspectors wroteBased on observation, interviews, medical record review, and facility P&P review, the facility failed to ensure the necessary means to call the staff for assistance was provided for one of 12 final sampled residents (Resident 27). * The facility failed to ensure the call light was visible and within Resident 27's reach. This failure posed a risk for the delay of care/assistance when the resident is unable to call for help.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to report an allegation of abuse to the CDPH, L&C Program, Long-Term Care Ombudsman, and local law enforcement officials in a timely manner for one of one resident (final sampled resident, Resident 15) reviewed for an abuse allegation. * The facility failed to timely report the allegations of abuse to the CDPH L&C Program, Long-Term Care Ombudsman, and local law enforcement after the facility was made aware of an allegation of abuse made by Resident 15 against the facility staff. This failure had the potential for the delay of the alleged abused investigation and the facility to not take prompt and appropriate corrective actions to prevent further abuse.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to one of one final sampled resident reviewed for allegation of abuse (Resident 15). * Resident 15's change in condition evaluation and monitoring was not completed and the physician was not notified of the allegation of the verbal and physical abuse from the staff. This failure had the potential for Resident 15 to not receive the necessary care and services to meet the highest practicable physical, mental, and psychosocial well-being.
Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain a safe water temperature levels in two of three rooms (Rooms A and C) tested for the water temperature. * The facility failed to ensure the water temperature in Rooms A and C were between 105-120 degrees Fahrenheit. In addition, when the facility conducted water temperature check, 12 of 27 rooms had sink water temperature of above 120 degrees Fahrenheit. This failure had the potential for the residents to sustain severe burn injury.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for one of two final sampled (Resident 4) and one nonsampled resident (Resident 61) reviewed for respiratory care. * The facility failed to administer the oxygen to Resident 4 as per the physician's order. *The facility failed to ensure the oxygen tubing was labeled for Resident 61. These failures had the potential for the residents to not receive the appropriate respiratory care, increased the risks of infection and affect the residents' well-being.
Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the pharmaceutical services to ensure the accurate administration of the medications. One of four licensed nurses (LVN 3) observed during the medication administration was found to have two medication errors. The facility's medication error rate was 8%. * LVN 3 failed to administer Resident 2's metformin (antidiabetic medication) 500 mg as ordered by the physician. * LVN 3 failed to administer Resident 53's ferrous sulfate (supplement) 325 mg as ordered by the physician. These failures had the potential to negatively impact the residents' health outcomes.
Inspectors wroteBased on observations, interview, medical record review, and facility's P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage, labeling, and disposal of medications. * A tube of Silicone Cream (a protective skin barrier which contains active medication ingredient to retain moisture and promote healing) was observed on the sink counter inside Resident 65's room. * The oral and non-oral medications were stored together inside the medication room. * The refrigerator inside the medication room was not kept clean. * Boxes of medical supplies were observed on the floor inside the medical supply storage room. These failures had the potential to negatively impact the residents' health outcomes.
Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to establish and maintain an infection control program 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 monthly infection surveillance documents showed if the residents' conditions met the McGeer's Criteria and if the residents listed in the surveillance log had HAI, CAI or suspected infection. * The facility failed to ensure Resident 4 was placed on EBP as per the physician's order. In addition, LVN 5 failed to perform hand hygiene before entering Resident 4's room. These failures had the potential to result in the spread of infection to the facility's vulnerable population.
Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the antibiotics were not prescribed to one of 12 final sampled residents (Resident 53) and one nonsampled resident (Resident 31) who did not meet McGeer's criteria in the surveillance log. * The facility failed to address the use of antibiotics when Resident 31 and 53's condition did not meet McGeer's criteria for true infection. This failure had the potential for the antibiotics to be used when it was not necessary and could result in the development of antibiotic-resistant bacteria.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the education on the risks and benefits of the vaccinations were reviewed with the resident and/or resident representative for eight of 11 residents (Residents 5, 6, 7, 27, 39, 49, 51 and 54) reviewed for immunization. * The facility failed to ensure Residents 5, 27, 49, 51, and 54 were provided education on the risk and benefits when the residents declined pneumococcal vaccination. * The facility failed to ensure Residents 6 and 39 and/or their representative was offered the pneumococcal vaccine and were provided with education on the risk and benefits of pneumococcal vaccination. * The facility failed to ensure Resident 7 received education on the risk and benefits when resident declined the influenza vaccination. [...]
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of 11 Residents (final sampled residents, Residents 7 and 27) reviewed for immunization were offered the COVID-19 seasonal vaccine. This failure posed the residents at risk for increased risk for infection and transmission of COVID-19.
Inspectors wroteBased on observation, interview, and facility documentation review, the facility failed to ensure seven of seven residents (final sampled Residents 4, 45, and 68; and nonsampled Residents 28, 35, 39, and 62) present in the residents' council meeting were provided with the required information. * Residents 4, 28, 35, 39, 45, 62, and 68 were not informed on how to contact the local State agency. This failure posed the risk of the residents not being able to file a complaint directly to the local State Agency.
Inspectors wroteBased on interview and medical record review, the facility failed to ensure the necessary transfer/discharge services was completed one of two closed record sampled residents (Resident 58). * The facility failed to ensure the LTC Ombudsman was made aware when Resident 58 was discharged from the facility. This posed the risk of the LTC Ombudsman not being aware of the circumstances should an appeal be filed by the resident or her representative regarding the transfer/discharge, and the risk of the resident or their representative not being aware of their rights prior to the transfer/discharge from the facility.
Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medical record for two of twelve final sampled residents (Residents 7 and 27) were accurate. * The Skilled Nursing Assessments for Residents 7 and 27 failed to show documentation the residents were receiving nebulizer treatment. This failure had the potential for Resident 7 and 27's care needs not being met as the medical record was inaccurate.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 3) received the appropriate services needed to maintain optimal nutritional status. * The facility failed to timely notify Resident 3's physician of the RD recommendations when Resident 3 had a weight loss of 6 pounds in six days. This failure had the potential for the resident to not receive the necessary care and intervention timely to maintain the resident's nutrition status and/or prevent further weight loss.
Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical record was accurate for one of two sampled residents (Resident 1). This failure posed the risk for Resident 1 to not receive the accurate and necessary care.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to follow the abuse protocol during the facility investigation period for one of two sampled residents (Resident 1). * The facility failed to suspend CNAs 2 and 3 from work when Resident 1 reported an allegation of physical abuse against these two CNAs on 11/10/24. This failure had the potential to place Resident 1 and other residents at risk of not being protected against the alleged abusers.
Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of two sampled residents (Resident 1) attained and/or maintained her highest practicable physical well-being. * The facility failed to monitor Resident 1's safety and psychosocial wellbeing and developed a care plan after Resident 1 had reported an abuse allegation on 11/10/24. This failure had the potential for Resident 1 not to receive the necessary care and services.
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 when: * The facility failed to ensure the kitchen utensils and equipment were stored or kept in sanitary conditions. * The facility failed to ensure the kitchen equipment were cleaned properly. * The facility failed to ensure a juice machine had an air gap for back flow prevention. These failures had the potential to pose the risk for exposure to food-borne illnesses in a medically vulnerable population of 42 residents received food prepared in the kitchen.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure whether it was safe to self-administer the medications for one of 14 final sampled residents (Resident 24). * Resident 24 was observed to have two Voltaren (topical pain medication) gel tubes at bedside. Resident 24 did not have the physician's order or care plan problem addressing the self-administration of medications. This failure had the potential for Resident 24 to administer the medications inaccurately.
Inspectors wroteBased on interview, medical record review, and facility P&P, the facility failed to ensure the advance directive information was documented and/or the information on how to formulate an advance directive was offered to three of 14 final sampled residents (Residents 22, 24, and 25). * The facility failed to ensure the copies of the advance directives were obtained and placed in the medical records for Residents 22 and 24. * The facility failed to ensure the POLST for Resident 25 was updated to show the advance directive was formulated. These failures had the potential for the facility to provide the treatments and services against the residents' wishes.
Inspectors wroteBased on interview and record review, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNOC) after the termination Medicare Part A services for two nonsampled residents (Resident 45 and 47). This failure had the potential for violating the residents' rights to be informed of changes for coverage.
Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the staff implemented two-person assist for transfers one of two final sampled residents (Resident 18) as per the plan of care, resulting the right ankle fracture treated with the right ankle splint. This failure had the potential to negatively impact the resident's well-being.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the timely intervention for one of three final sampled residents (Resident 22) reviewed for weight loss. * Resident 22 experienced a 5.32% weight loss in one month. There was no assessment from nutritional services, RD intervention, care plan, and notification to the MD and family regarding the weight loss. This failure had the potential to result in continued nutritional decline and negative outcomes.
Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate reconciliation and disposal of medications. * The facility failed to ensure the count performed for all controlled medications in the Omnicell (automatic drug delivery system) as per the facility's P&P. This failure posed the risk for diversion of medications.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 12) was properly monitored for the stool softener medications. This failure had the potential to negatively impact the resident's health condition.
Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 25) reviewed for unnecessary medications was free from the unnecessary psychotropic medications (medication that affects the mind, emotions, and behavior). This failure had the potential for Resident 25 to have adverse complications from the medication.
Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed ensure proper storage and label of medications in Medication Cart 1 and medication storage room when: * Resident 7's eye drop medication in Medication Cart 1 was not kept in the refrigerator as per the medication instruction. * Resident 22's cough medication was stored with the topical ointment medication in Medication Cart 1. * Resident 686's inhalation medication in Medication Cart 1 was not labeled with an opened date as per the facility's policy . * The bottom drawer of Medication Cart 1 was not kept clean and free from spill residue. * The expired medication was stored in the medication storage room. In addtion, the licensed nurse left the medications for Resident 27 unattended while performed other tasks. [...]
Inspectors wroteBased on interview and facility document review, the facility failed to ensure the DSS who was responsible to oversee the satellite kitchen which produced food for the skilled nursing facility was qualified in managing the day-to-day functions of the food services department. This failure had the potential to negatively affect the health and well-being of 42 residents who received the food prepared in the kitchen.
Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the food allergy item was not served to one of 14 final sampled Residents (Resident 27). This failure had the potential for the resident's medical complication.
Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to ensure the education was provided to the staff and family/visitors on safe food handling of outside food. This failure had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from outside sources.
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 14 final sampled residents (Resident 22) reviewed for hospice services. * The facility failed to ensure Resident 22 received hospice aide visit one time per week as ordered by the physician. * The facility failed to ensure the hospice log showed documentation regarding the CHHA visit. * The facility failed to ensure the hospice RN was included in Resident 22's Care Conference/Care Plan Meeting on 9/27/24. These failures had the potential for not providing necessary care and services to the resident recievieng hospice services.
Inspectors wroteBased on observation, interview, medical record review, and facility documentation review, the facility failed to ensure the QA committee identified and developed action plans to address the focused areas from the last recertification survey. The QA committee failed to have documented evidence to show they identified and developed action plan to correct the identified concern of the respiratory care and medication storage. This failure had the potential to result in residents at risk for possible infection and causing adverse side effects for expired medication.
Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the safe and sanitary environment to help prevent the development and transmission of infection when: * The facility failed to maintain the accurate infection surveillance program for September and October 2024. * The facility failed to ensure the infection control practices were implemented in the facility's laundry room. * The facility failed to ensure the licensed nurse (LVN 1) performed hand hygiene in between changing gloves during the medication administration observation for Resident 27. * The facility failed to ensure Foley catheter care for Resident 686 was done in the safe and sanitary manner. [...]
Inspectors wroteBased on interview, facility document, and facility P&P review, the facility failed to implement the antibiotic stewardship program. * The facility failed to ensure the appropriate use of antibiotics for one final sampled resident (Resident 25) and two nonsampled residents (Residents 9 and 20). This failure had the potential for inappropriate use and increased risk of drug resistant organisms.
Inspectors wroteBased on interview, medical record review, and the facility P&P review, the facility failed to ensure two of 14 final sampled residents (Residents 4 and 25) were offered the influenza vaccine (vaccine given to protect the resident from influenza disease) and pneumococcal vaccine (a vaccine given to protect the resident from pneumococcal disease) when the residents were eligible to receive in accordance with the current CDC's guidelines and recommendations. This posed the risk of Residents 4 and 25 acquiring influenza and pneumonia.
Inspectors wroteBased on interview, facility document review, and facility' P&P review, the facility failed to maintain the safe operating conditions. * The facility failed to maintain the essential temperature logs for the safe operating conditions of the Omnicell Anatomic Drug Dispensing system. This failure had the potential for the equipment to not function in the way intended, which could negatively affect the residents' medications.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 14 final sampled residents (Resident 22) and one nonsampled resident ( Resident 17) reviewed for respiratory care were provided with the appropriate respiratory services. * The facility failed to ensure Resident 17's nasal cannula was stored in a sanitary manner when not in use. *The facility failed to ensure Resident 22's nasal cannula tubing and respiratory storage bag were dated. These failures had the potential to affect the respiratory health and well-being of the residents received respiratory care in the facility.
Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the main menus were followed for 42 of 42 residents who consumed food prepared in the kitchen. This failure had the potential for the residents to not receive the menus as planned.
Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the expired food items in the walk-in refrigerator and dry storage area were discarded. * The facility failed to ensure the labeling and dating of foods in the kitchen and refrigerator used for the residents' food brought in by the visitors were proper. * The facility failed to ensure the kitchen equipment was clean. * The facility failed to ensure the resident dishware and utensils had a smooth cleanable surface. * The facility failed to ensure the sanitizer test strips had not expired. * The facility failed to ensure the backflow prevention of one air gap was properly maintained. [...]
Inspectors wroteBased on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed to maintain the infection control program designed to provide the safe environment and reduce the risk of development of illnesses and transmission of diseases. * The facility failed to show documentation of the Legionella (a bacteria that can cause a serious type of lung infection) facility risk assessment and testing protocols. * The facility failed to implement proper hand hygiene and changing gloves during wound care. * The facility failed to ensure a confirmed COVID-19 case was assessed every four hours for respiratory rates, temperatures, and oxygen saturation levels as per the facility's P&P for Resident 25. * LVN 2 failed to disinfect the self-sealing stopper top of the insulin (medication to lower blood sugar) vial prior to withdrawing the medication. [...]
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure a quarterly care conference was conducted for one of 14 final sampled residents (Resident 14). * Resident 14's last quarterly care conference was conducted on 9/20/22. The residents' care conferences were scheduled on a quarterly basis. However, there was no documentation of any other care conferences conducted for Resident 14 after 9/20/22. This posed the risk of violating the rights of Resident 14 and/or responsible party to participate in choosing the treatment options and making the decisions in care planning.
Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 736) who could not safely self-administer medications had the medication at the bedside. This failure had the potential for Resident 736 to administer medications inaccurately.
Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the Long-Term Care Ombudsman (a person who routinely visits the facility and advocated for the residents) was notified of the discharge for one of three closed record sampled residents (Resident 28). This failure had the potential of not providing Resident 74 with access to an advocate who could inform them of their options and rights related to discharge.
Inspectors wroteBased on observation, interview, and facility document review, the facility failed to provide an individualized and ongoing activity program to meet the needs and interests of one of 14 final sampled residents (Resident 2) and one nonsampled resident (Resident 11). * The facility failed to provide activities for Residents 2 and 11 to meet the resident's identified interests. The facility failed to ensure the TV remote controls were provided for Residents 2 and 11. This had the potential for the residents to experience feelings of social isolation and frustration.
Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure one of 14 final sampled residents (Resident 10) on hospice services attained and maintained their highest practicable well-being. * The facility failed to communicate with the hospice agency regarding the RN/ LVN and CHHA visitation when Resident 10 was in isolation for Covid-19. This had the potential of a delay in hospice care regarding changes in Resident 10's condition.
Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure one of 14 final sampled residents (Resident 10) who required hearing aids received proper treatment and assistive device to maintain her hearing abilities. * The facility failed to ensure Resident 10's hearing aids were applied as ordered by the physician. This had the potential for the resident's communication to be impaired by not being to hear conversations clearly.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services related to pressure injuries (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore to promote wound healing) were provided to one of 14 final sampled residents (Resident 17). * The facility failed to ensure the low air loss mattress setting was consistently monitored to ensure the appropriate settings of the low air loss mattress for Resident 17. This failure posed the risk for complications and delayed wound healing.
Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary respiratory care and services for one of 14 final sampled residents (Resident 538). * The facility failed to ensure Resident 538's nasal cannula tubing (medical device use to deliver supplemental oxygen) was dated. This had the potential for increased risks of infection.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services for one of 14 final sampled residents (Resident 12) and two nonsampled residents (Residents 7 and 18). * Resident 18's hydrocodone-acetaminophen (a narcotic pain medication) Controlled Drug Record documentation did not match Resident 18's MAR. This failure posed the risk of diversion of the controlled medication. * Resident 12's chewable aspirin medication (medication used to lower the chance of heart attack) was administered without the instructions for the resident to chew, and the resident swallowed the aspirin tablet. This posed the risk of decreased absorption of Resident 12's medication. * Resident 7's ferrous sulfate (iron supplement) and calcium (calcium supplement) were administered at the same time. [...]
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure four of 14 final sampled residents (Residents 2, 21, 30, and 537) were free from unnecessary psychotropic medications (medication that affects the brain activity). * The facility failed to provide the physician's documentation to extend Resident 30's Xanax medication (psychotropic medication) after 14 days of PRN use and the facility failed to provide a stop date on Resident 30's PRN Xanax ordered on 1/29/23. * The facility failed to provide the non-pharmacological interventions to Resident 21's depression, anxiety, and poor intakes to minimize the use of alprazolam, mirtazapine, and escitalopram medications (psychotropic medications). * The facility failed to accurately document Resident 21's monthly behavior tracking for mirtazapine use. [...]
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to store the medication and supplies according to the manufacturer's recommendations. * Medication Cart 2 had Resident 16's Novolin R FlexPen insulin injection (medication used to lower blood sugar) with an opened date of 12/29/22, and labeled to expire on 1/27/23. This failure had the potential for the administration of deteriorated medication. * Medication Cart 3 had the expired IV supplies. This had the potential for use of expired supplies. * The facility failed to store the A&D ointment securely and inaccessible by the residents and visitors. This had the potential for unauthorized access to the medication.
Inspectors wroteBased on interview and medical record review, the facility failed to provide the rehabilitation services for one of 14 final sampled residents (Resident 30). * The facility failed to ensure Resident 30 was provided RNA services for ambulation when Resident 30 was in isolation for Covid-19. This failure had the potential for Resident 30 to decline in the resident's range of motion and mobility.
19 fire safety citations on file: 2 on November 26, 2025, 4 on October 24, 2024, 13 on February 10, 2023.
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) | 5.03 | 4.52 | 3.86 |
| Registered nurses | 0.70 | 0.67 | 0.69 |
| All nursing staff on weekends | 4.28 | 4.09 | 3.42 |
| Nurse aides | 2.86 | ||
| Licensed practical nurses | 1.47 | ||
| Nursing staff turnover (share who left in a year) | 35.8% | 36.7% | 45.8% |
| Registered nurse turnover | 14.3% | 38.1% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.95 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 5.32 on weekdays and 4.28 on weekends, 20% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 1.2% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 5.03 in April to June 2025 to 5.03 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 | 5.03 | 0.70 | 5.32 | 4.28 | 1.2% | 0 of 90 | 40 |
| Oct to Dec 2025 | 5.01 | 0.73 | 5.24 | 4.44 | 3.7% | 0 of 92 | 39 |
| Jul to Sep 2025 | 5.07 | 0.77 | 5.33 | 4.40 | 5.9% | 0 of 92 | 40 |
| Apr to Jun 2025 | 5.03 | 0.76 | 5.28 | 4.38 | 4.1% | 0 of 91 | 39 |
| 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.
| 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 | 8.9 | 10.3 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.7 | 0.8 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.4 | 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 | 0.4 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 14.8 | 9.8 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.3 | 4.3 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 10.6 | 12.0 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 20.6 | 22.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 8.3 | 11.2 | 12.0 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Freedom Village Healthcare Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (67.9% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
67.9% 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. 164 eligible stays.
10.8% 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. 168 eligible stays.
7.7% 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. 94 eligible stays.
33.0% 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. 103 residents counted.
0.7% 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. 144 residents counted.
0.9% 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. 144 residents counted.
100.0% this home
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. 97 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: CASA PACIFICA.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Cdr Investment Group, LLC | 5% or greater indirect ownership interest | Organization | 12/31/2025 | |
| Freedom Group-California LLC | 5% or greater indirect ownership interest | Organization | 10/26/1989 | |
| R.j. Wade Limited Partnership, LLP | 5% or greater indirect ownership interest | Organization | 10/26/1989 | |
| Stringer Family Partnership | 5% or greater indirect ownership interest | Organization | 06/01/2009 | |
| Debban, Susan | 5% or greater indirect ownership interest | Individual | 10/26/1989 | |
| Francese, Celia | 5% or greater indirect ownership interest | Individual | 03/17/2026 | |
| Kubicka, Charles | 5% or greater indirect ownership interest | Individual | 10/26/1989 | |
| Mangiaracina, Emily | 5% or greater indirect ownership interest | Individual | 01/01/2022 | |
| Murphy, Timothy | 5% or greater indirect ownership interest | Individual | 01/05/2020 | |
| Roskamp, Cheryl | 5% or greater indirect ownership interest | Individual | 01/01/2026 | |
| Roskamp, Denise | 5% or greater indirect ownership interest | Individual | 01/01/2026 | |
| Roskamp, Randall | 5% or greater indirect ownership interest | Individual | 01/01/2026 | |
| Roskamp, Robert | 5% or greater indirect ownership interest | Individual | 10/26/1989 | |
| Roskamp, Steven | 5% or greater indirect ownership interest | Individual | 01/01/2022 | |
| Stringer, Thomas | 5% or greater indirect ownership interest | Individual | 10/26/1989 | |
| Wade, Richard | 5% or greater indirect ownership interest | Individual | 10/26/1989 | |
| Roskamp, Cheryl | Operational/managerial control | Individual | 12/09/2020 | |
| Stewart, Selina | Operational/managerial control | Individual | 03/27/2026 | |
| Suckiel, Jennifer | Operational/managerial control | Individual | 06/15/2019 | |
| Freedom Properties West LLC | General partnership interest | Organization | 01/01/1986 | |
| Hemet Retirement Properties West, LLC | General partnership interest | Organization | 01/01/2025 | |
| Quantum Basics II, LLC | General partnership interest | Organization | 01/05/2020 | |
| Tarayan Inc | General partnership interest | Organization | 10/26/1989 | |
| Casino, Marianne | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 05/29/2026 | |
| Roskamp, Ruth | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 05/29/2026 | |
| Freedom Management Co LLC | Adp of the SNF | Organization | 05/29/2026 | |
| Mangiaracina, Emily | Adp of the SNF | Individual | 06/01/2020 | |
| Roskamp, Cheryl | Adp of the SNF | Individual | 12/09/2020 | |
| Stewart, Selina | Adp of the SNF | Individual | 03/27/2026 | |
| Suckiel, Jennifer | Adp of the SNF | Individual | 06/15/2019 | |
| Tabatabai, Ali | Adp of the SNF | Individual | 01/01/2023 |
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.