Home / California / Garden Grove
12681 Haster Street, Garden Grove, CA 92840 · Orange County · (714) 971-2153
124 certified beds, about 117 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1996
CMS Care Compare ratings, data as of September 1, 2026 · CCN 555667 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on June 3, 2025, inspectors cited 13 health deficiencies (the California average is 15.6, the national average 9.2).
None of its 73 health citations since April 2021 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 4.31 hours per resident per day, against 4.52 across California and 3.86 nationally. Registered nurses accounted for 0.32 of those hours.
34.8% of nursing staff left within the year CMS measured (California average 36.7%).
CMS links it to David Johnson, an affiliated group of 48 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 73 health citations on file.
Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) attained and maintained the highest practicable well-being. * The facility failed to administer Resident 1's clonidine (antihypertensive) medication and notify the physician when Resident 1's SBP was more than 160 mmHg as per the physician's orders. This failure posed the risk of not providing appropriate and consistent care to Resident 1.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurate for two of three sampled residents (Residents 1 and 2). * The facility failed to ensure Resident 1 and 2's Fall Risk assessment were accurate. These failures posed the risk for the residents to not receive the necessary care and interventions.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 2) was free from misappropriation of property. * The SSD failed to follow up with Resident 2 and conduct an investigation after being informed Resident 2 was missing three pairs of earrings. 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 notify the resident's physician of a change in condition for one of three sampled residents (Resident 1). * The facility failed to notify Resident 1's physician regarding the resident's episode of verbal aggression towards the staff. This failure had the potential for Resident 1 not to receive appropriate and timely care and services.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent or minimize injuries from a fall for three of six sampled residents (Residents 2, 3, and 6) reviewed for falls. * Resident 2 had a history of a fall, however, the care plan for the floor mats were not resident centered for Resident 2's fall. * Resident 3 had a history of falls, however, the facility failed to ensure the 72-hour neurological assessments (assessment of the brain, and nervous system used to detect, manage, and track neurological changes or damage) were conducted completely. In addition, the facility failed to ensure the bilateral floor mats were provided, and the 24-hour orthostatic blood pressures (sudden drop in blood pressure that occurs when standing up) were conducted. [...]
Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the appropriate use of restraints including consent, physician's order, skin assessment, removal of restraint, and ROM exercises were provided for one of six sampled residents (Resident 2) reviewed for restraints. * Resident 2 did not have a physician's order, informed consent, assessment, or monitoring for the use of the bilateral soft mittens. In addition, there was no documentation of the mittens removal, and if the hands were assessed and exercised every two hours. These failures had the potential for the increased risk of resident's skin and soft tissue injury as well as the decrease in the ROM functions related to the restraint use.
Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to thoroughly investigate an allegation of facility staff to resident physical abuse for one of three sampled residents (Resident 1) when * Resident 1 alleged that her caregiver (CNA) physically abused her. The facility staff tasked with conducting potential resident witness interviews, failed to provide the facility's Abuse Coordinator with an interview conducted with Resident 1's roommate (Resident 2), who was present during the time Resident 1 alleged to have been physically abused. This failure potentially inhibited the facility's ability to determine if resident abuse occurred and posed the risk for further abuse.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of five final sampled residents (Resident 4) attained and maintained their highest practicable well-being. * The facility failed to continuously monitor Resident 4 after the resident had a witnessed fall. This failure had the potential for not providing the necessary care and services if the residents had a change in condition.
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 as evidenced by: * The facility failed to ensure the kitchen utensils were clean and free of food particles or residues. * The facility failed to ensure the kitchen utensils had smooth cleanable surface and in good condition. * The facility failed to ensure the heavy-duty blender used for puree preparation, the scoops used for food portioning, and the plastic bucket containers used for the fruits and food storage were air dried prior to storing and stacking. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. [...]
Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the reasonable accommodation to meet the needs of one final sampled resident (Resident 75) reviewed for communication needs. * The facility failed to ensure Resident 75 was provided with the means to communicate his daily needs. This failure had the potential to negatively impact the resident's psychosocial well-being or result in delayed provision of care.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the freedom from unnecessary drugs for three of 23 final sampled residents (Residents 86, 93, and 914) and one nonsamples resident (Resident 15). * The facility failed to ensure an physician's order for the temazepam medication was obtained prior to administering the medication to Resident 15. * The facility failed to ensure the non-pharmacological interventions were implemented prior to administering the venlafaxine (antidepressant medication) and buspirone (antianxiety medication) medications, and to monitor the side effects of psychotropic medications to Resident 86. * The facility failed to ensure non-pharmacological interventions were implemented prior to administering the sertraline (antidepressant medication) to Resident 914. [...]
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one final sampled resident (Resident 90) reviewed for ADL care was provided with the necessary care and services to maintain their ADL capabilities. * The facility failed to ensure the care and services were provided to maintain good grooming and personal hygiene when Resident 90's left ear was observed with a large amount of brownish cerumen covering the left ear canal. This failure had the potential to negatively affect the resident's well-being.
Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for one of two residents reviewed for smoking (final sampled resident, Resident 50). In addition, the facility failed to assess following multiple unwitnessed falls for one of one final sampled resident (Resident 21) reviewed for falls. * The facility failed to complete the neurological assessments following unwitnessed falls on 3/27, 4/25 and 5/1/25, for Resident 21. * The facility failed to ensure the safe smoking practices were followed for Residents 50 when the resident was permitted to keep the cigarettes with his possession after being assessed as requiring supervision while smoking. [...]
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 75) reviewed for catheter care received the appropriate care and services for an indwelling urinary catheter. This failure had the potential for the resident to develop complications associated with the use of the indwelling urinary catheter.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for three of 23 final sampled residents (Residents 84, 96, and 915) and one nonsampled resident (Resident 71) reviewed for oxygen therapy. * The facility failed to follow the physician's order for Residents 84 and 96's oxygen therapy. * The facility failed to ensure the oxygen tubing for Resident 71 was labeled with the date. * The facility failed to ensure the administration of oxygen to Resident 915 was documented in the TAR. In addition, the facility failed to monitor Resident 915 for SOB or wheezing as an indication of the use of oxygen as per the physician's order. These failures had the potential for the residents to not receive the appropriate care and may negatively impact on the residents' medical conditions.
Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the competency of four of six licensed nurses (LVN 1, RN 1, DSD, and DON) observed in performing a control solution check with the glucometer. LVN 1, RN 1, the DSD, and DON were unable to demonstrate the competency in the quality control of the glucometer. This failure had the potential of not providing care to the residents in a safe and competent manner.
Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided when: * The facility failed to ensure the complete documentation for the destruction of medications. * The facility failed to ensure LVN 7 administered the medications to Resident 86 via the correct route. LVN 7 administered the medications to Resident 86 via GT, and not orally as per the physician's order. These failures had the potential for drug diversion and to cause ineffective treatment and complications from the medications administered.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two final sampled residents (Residents 86 and 914) and two nonsampled residents (Residents 41 and 916) were free from the unnecessary medications. * The facility failed to ensure Resident 41 was not administered the metoprolol (antihypertensive) and amiodarone (antiarrythmic) medications without parameters when to hold or administer the medications. * The facility failed to ensure Resident 914 was not administered the carvedilol (antihypertensive medication) without monitoring the resident's blood pressure and heart rate as per the physician's order. * The facility failed to ensure Resident 916 was not administered the hydralazine (antihypertensive medication) when the SBP less than 160 mmHg as per the physician's order. [...]
Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 54.29%. Two of the two licensed nurses (LVNs 7 and 8) who were observed during medication administration were found to have errors. * LVN 7 failed to administer the Eliquis (anticoagulant medication) medication to Resident 41. * LVN 7 failed to ensure the medications were not administered together when administering medications via the GT to Resident 86, and to flush the GT in between the medications and after the administration of the medications. * LVN 7 failed to administer the artificial tears to Resident 86. * LVN 8 failed to ensure Resident 6 received the correct amount of prescribed eye medication. [...]
Inspectors wroteBased on observation, interview, medical record review, facility documentation review, and facility P&P review, the facility failed to ensure the removal of the discontinued medications from one of six medication carts (Medication Cart 4) inspected. This failure had the potential to result in drug diversion of controlled medications and the administration of medication without a physician's order.
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 the safe and sanitary environment and help prevent the development and transmission of diseases and infections for one final sampled resident (Resident 6) and one nonsampled resident (Resident 99) observed for medication administration, and one final sampled resident (Resident 75) observed for personal hygiene. * LVN 8 failed to perform hand hygiene prior to administering the eye medication to Resident 6 after touching the privacy curtain. * LVN 8 failed to perform hand hygiene and change gloves before administering the medication via GT after touching the enteral feeding pump to Resident 99. In addition, hand hygiene was not performed prior to donning new gloves after cleaning the medication tray and overbed table. [...]
Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure themedical records were complete and accurately maintained for two of ten sampled residents (Residents 9 and 10). * Residents 9 and 10's medical records failed to show the monitoring of the residents' locations was completed on 3/9, 3/10, and 3/12/25. These failures had the potential for the residents' care needs to not be met as their medical information was inaccurate and incomplete.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to update the plan of care for one of four sampled residents (Resident 1). * Resident 1's care plan problem was not updated to address the low hematocrit (measurement of the percentage of red blood cells in the blood) and hemoglobin (protein in red blood cells that carries oxygen) levels. This failure had the potential to affect the provision of care for Resident 1.
Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide an accurate surveillance and assessment of the skin and soft tissue infection for one of four sampled residents (Resident 4). This failure posed the risk for not identifying and managing Resident 4's skin infection.
Inspectors wroteBased on interview and medical record review, the facility failed to administer the medications as ordered by the physician for one of four sampled residents (Resident 3). * Resident 3 had a physician's order for insulin glargine (a medication used to treat diabetes) to be given at bedtime, with parameters to hold if the blood sugar levels were less than 120 mg/dl. There was no documented evidence the blood sugar level was checked to determine whether to administer or hold the insulin as ordered. This failure put Resident 3 at risk of complications.
Inspectors wroteBased on interview and medical record review, the facility failed to notify the resident's representative when there was a change of the POA for one of four sampled residents (Resident 1). * Resident 1's legal representative was changed from Family Member 1 to Family Member 2 without informing Family Member 1. This failure resulted in Family Member 1 being unaware of the change, which had the potential to negatively impact the resident's well-being.
Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure a physician's order was in place prior to the use of an indwelling urinary drainage catheter for one of four sampled residents (Resident 3). This failure put Resident 3 at risk of complications and not having their care needs met.
Inspectors wroteBased on interview and medical record review, the facility failed to ensure the accuracy of the medical record for one of the two sampled residents (Resident 1) was complete and accurate. * The facility failed to ensure Resident 1's Change in a Resident's Condition or Status was initiated. This failure had the potential for the resident's care needs to not be met as their clinical information was incomplete.
Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the kitchen staff were competent in the position related duties when: 1. Two of four cooks (Cooks 1 and 4) failed to perform the following: a. Failed to prevent cross contamination, b. Failed to perform proper hand hygiene during food preparation, c. Failed to sanitize food preparation equipment when washed manually, d. Failed to sanitize food preparation surfaces, and e. Failed to follow the recipes. 2. One of four cooks (Cook 1) failed to know the final cooking temperature of chicken. 3. One of seven DA (DA 1) failed to know the manual dish washing procedure. 4. One of seven DA (DA 2) failed to follow the resident menu. [...]
Inspectors wroteBased on observation, interview, facility document review, and P&P review, the facility failed to ensure the professional standards for food safety and sanitation guidelines were followed when: 1. Potential for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) was not prevented. A scoop was stored in the instant mash potato container and the kitchen staff did not use proper color coded cutting board when cutting raw chicken and vegetable. 2. Time Temperature Control for Safety (TCS) Foods (food that require time and temperature controls to limit the growth of illness causing bacteria) were not handled safely as no cooling down log for the leftover chicken and turkey cooked on the previous day. 3. Proper hand hygiene was not performed by the kitchen staff. 4. [...]
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure seven of 24 final sampled residents (Residents 52, 54, 60, 67, 85, 99, and 422) were provided with the appropriate respiratory care when: * The facility failed to administer the oxygen therapy as ordered and failed to ensure the titration oxygen order included the parameters as to how to titrate the oxygen flow rate. * The facility failed to ensure Residents 85 and 422 were provided with continuous oxygen therapy per the physician's order. In addition, the facility failed to ensure Resident 422's nebulizer mask was changed weekly and stored properly per the facility's P&P. * The facility failed to ensure Resident 60's oxygen therapy tubing was changed weekly per the facility's P&P. [...]
Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure an adequate oversight of the kitchen was provided when multiple issues were identified in regard to the kitchen safety and sanitation, following the facility's recipes, and monitoring of the kitchen staff' competency. This failure had the potential to result in food not being served in a safe and sanitary manner which could lead to foodborne illness and resident nutritional needs not being met for the 115 facility residents who received food prepared in the kitchen.
Inspectors wroteBased on observation, interview, facility document and P&P review, the facility failed to ensure the resident menu was followed as evidenced by: 1. Puree vegetable recipes were not followed for the American and Vietnamese menus. 2. Puree meat recipes were not followed for the American and Vietnamese menus. 3. Puree cake recipe was not followed for all menus. 4. Puree rice recipe was not followed for the Vietnamese menu. These failures posed the risk for an inconsistent product and to not meet the nutritional needs of the 23 residents who received puree diets.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide reasonable accommodations to meet the needs of one of 24 final sampled residents (Resident 422). * The facility failed to ensure Resident 422's call light was within the resident's reach. This failure created the potential to negatively impact the resident's psychosocial well-being or result in a delay to provide care.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure three of 24 final sampled residents (Residents 20, 54, and 77) had copies of their advance directive (written instruction, recognized under State law, relating to the provision of health care when the individual is incapacitated) in their medical records. This failure had the potential to go against the health care wishes of the Residents 20, 54, and 77.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure a significant change of status assessment was completed with 14 days after a significant change in the resident's physical or mental condition had been determined for one of 24 final sampled residents (Resident 101). This had the potential of not providing the appropriate care and services to Resident 101 based on the resident's current status.
Inspectors wroteBased on interview and medical record review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for four of 24 final sampled residents (Resident 18, 45, 107, and 422). * The facility failed to develop a care plan problem to address Resident 422's use of apixaban (anticoagulant medication) and Melatonin (medication to aid with sleep). * The facility failed to ensure a care plan problem addressing Resident 422's use of lorazepam (antianxiety medication) was accurate to reflect the resident's behavior manifestation as ordered by the physician. * The facility failed to ensure a care plan problem addressing the dialysis access site was accurate to reflect Resident 18's dialysis access site. [...]
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for one of 24 final sampled residents (Resident 51). * The facility failed to follow the physician's order to record Resident 51's I&O every shift for 30 days. This failure had the potential risk of not providing the appropriate care for Resident 51. Medical record review for Resident 51 was initiated on 5/16/23. Resident 51 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 51's Order Summary Report showed a physician's order dated 4/26/23, to record I&O every shift for 30 days. However, further review of Resident 51's medical record failed to show documented evidence the resident's I&O was recorded as per the physician's order. [...]
Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure one of 24 final sampled residents (Resident 101) was provided with the appropriate bed to promote the healing of the pressure injury. This failure posed the risk for Resident 101's pressure injury to deteriorate and develop additional pressure injuries.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 24 final sampled residents (Residents 87 and 96) were provided with the necessary indwelling urinary catheter care to prevent UTI. This failure had the potential to put Residents 87 and 96 at risk for UTI.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of the 24 final sampled residents (Resident 99) received the appropriate treatment and services to prevent the occurrences of complications from GT feeding. * The facility failed to ensure Resident 99's head of bed was elevated during GT feeding to reduce the risk of aspiration. 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 appropriate pain management was provided to one of 24 final sampled residents (Resident 20). * The licensed nurse failed to clarify with the physician regarding two different orders for pain scale for Resident 20. In addition, the medication prescribed for moderate pain was administered for a severe pain, and there were no documented non-pharmacological interventions provided to Resident 20 prior to the administration of the pain medication. These failures posed the risk of Resident 20's pain not being managed appropriately.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the licensed nurse coordinated with the physician regarding the sevelamer carbonate (a medication that can lower the amount of phosphorus in the blood of residents receiving kidney dialysis) scheduled at the time when the resident was out to the dialysis center for one of 24 final sampled residents (Resident 18). Resident 18 did not receive the medication as ordered by the physician on the dialysis days. This failure posed the risk for Resident 18 to not be provided with the appropriate care and treatment and sustained possible medical complications that could had been avoided when the physician's order was followed.
Inspectors wroteBased on observation, interview, medical records review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs of one of 24 final sampled residents (Resident 5) and three nonsampled residents (Residents 22, 90, and 822). * The facility failed to ensure Resident 22's Lactulose (medication to treat constipation) was administered as ordered. * The facility failed to ensure the Norco (controlled pain medication) for Resident 5 was documented in MAR when administered. * The facility failed to ensure the Norco for Resident 90 was documented in the MAR when administered. * The facility failed to ensure the medications were not left unattended by a licensed nurse during medication administration. * The facility failed to ensure the wasting of controlled medication was performed by two licensed nurses. [...]
Inspectors wroteBased on interview, medical record review, facility P&P review, and facility document review, the Pharmacy Consultant failed to identify and recommend for monitoring of the side effects for enoxaparin (anticoagulant medication which reduces the chance of getting blood clots) for one of 24 final sampled residents (Resident 92). This failure had the potential risk of providing Resident 92 unnecessary medication and the potential for the development of significant side effects.
Inspectors wroteBased on interview and medical record review, the facility failed to ensure three of 24 final sampled residents (Residents 77, 92, and 422) were free from unnecessary medications. * The facility failed to monitor for signs and symptoms of bleeding related to Residents 422 and 77's use of apixaban (anticoagulant medication used to prevent blood clots). * The facility failed to monitor for signs and symptoms of side effects related to Resident 422's use of Reglan (medication used to treat nausea and vomiting). * The facility failed to monitor for signs and symptoms of bleeding related to Resident 92's use of enoxaparin (anticoagulant medication used to prevent blood clots). * The facility failed to ensure Resident 422's anti-bacterial medication order had a stop date. [...]
Inspectors wroteBased on the interview, medical record review, and facility P&P review, the facility failed to ensure two of 24 final sampled residents (Residents 77 and 422) were free from unnecessary psychotropic medications (any drug which afftects brain activities associated with mental processes and behavior). * The facility failed to ensure the non-pharmacological interventions were provided to Resident 422 for the use of lorazepam PRN and melatonin. In addition, the facility failed to ensure a rationale was documented for extending the duration of the use of lorazepam for Resident 422. * The facility failed to ensure non-pharmacological interventions were provided to Resident 77 for the use of clonazepam (antianxiety medication). [...]
Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 23.33%. Two of two licensed nurses (LVNs 7 and 8) were found to have made errors during the medication administration. * Resident 22 had the physician's order to mix lanzoprazole (a medication which reduces the amount of acid in the stomach) with apple sauce/apple juice; however, LVN 8 mixed the medication with water instead of apple juice as ordered. * Resident 22 had the physician's order for lactulose (medication to treat constipation); however, LVN 8 did not administer the medication as ordered. * Resident 22 had the physician's order for Oscal and D3 500/200 (supplement); however, LVN 8 did not administer the correct dose as ordered. [...]
Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of medications. * The facility failed to ensure the expired medications were removed from Treatment Cart A and Medication Room B. * The facility failed to ensure Resident 45's medication requiring refrigeration was stored in the medication refrigerator. * The facility failed to ensure the discontinued eye drop medication was removed from Refrigerator A. * The facility failed to ensure the opened insulin pens and medication vial labeled with open date more than 30 days for Residents 25, 56, and 100) were removed from stock or Medication Cart A. * Two bottles of pain-relieving oil were observed on Resident 53's bedside table. These failures had the potential to negatively impact the residents' well-being; [...]
Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure one of 24 final sampled residents (Resident 51) was provided with food prepared in a form to meet the resident's individual need. * The facility failed to ensure Resident 51 was provided with pureed dessert as per the resident's diet order. This failure posed the risk for Resident 51 to develop complications like aspiration (accidental breathing in food or fluid into the lungs) and choking.
Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the residents' family members and visitors were trained on safe food handling practices of food brought to the residents by the family members and other visitors. This failure posed the risk for the residents to have foodborne illness.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to maintain the accurate and complete medical records of one of three final closed record sampled residents (Resident 121). * The facility failed to the POLST was voided as per the facility's P&P when Resident 121's family member requested to change the treatment options and failed to ensure one of three copies of Resident 121's POLSTs was in the medical record. This failure has the potential to put the resident at risk for a delay in necessary care and treatment.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the proper infection control practices were followed for two of 24 final sample residents (Residents 72 and 106). * The facility failed to ensure RN 1 performed handwashing during the preparation of parenteral medication. This failure had the potential for Resident 72 getting infected and posed the risk of spreading infection to another resident. * The facility failed to ensure CNA 3 followed the contact precautions when providing care for Resident 106 who was on enhanced standard precaution. This posed the risk for the transmission of disease-causing microorganisms
Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the essential kitchen equipment was maintained in safe operating condition when: 1. The walk-in ceiling fan cover had a brown residue resembling rust. 2. The reach-in freezer had ice build-up. 3. The manual dish machine draining table was not properly attached to the adjoining dish machine draining table. Failure to maintain necessary kitchen equipment in proper working order may result in compromised food safety.
Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure three of three garbage dumpsters were contained and covered. This failure had the potential to attract pest and rodents that carry diseases.
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 proper labeling and dating of foods in the kitchen and refrigerator used for the residents' food brought in by the visitors. * The facility failed to ensure the proper thawing of meats in the refrigerator. * The facility failed to ensure the proper hand hygiene performed by the kitchen's staff. * The facility failed to ensure the proper use of sanitizing solution. * The facility failed to ensure the kitchen equipment and utensils were cleaned. * The facility failed to air dry equipment. 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, and facility P&P review, the facility failed to ensure the call light system was within reach for one of 23 final sampled residents (Resident 18) and one nonsampled resident (Resident 58). This failure had the potential for the residents to not receive timely care and assistance from the staff.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to maintain a copy of the resident's advance directive in the medical record for one nonsampled resident (Resident 34). This had the potential for the resident's decisions regarding their healthcare and treatment options not being honored.
Inspectors wroteBased on observation, interview, and medical record review, the facility failed to implement the plan of care to reflect the individual care needs for one of 23 final sampled residents (Resident 79) and two nonsampled residents (Residents 44 and 60). * The facility failed to ensure Resident 79 had bilateral floor mats and foot cradle in place. * The facility failed to ensure Residents 44 and 60 were provided with two-person assist with their ADLs. These failures posed the risk of not providing appropriate, consistent, and individualized care to the residents to attain or maintain their highest practicable physical well-being.
Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary care and services to ensure two of 23 final sampled residents (Residents 16 and 79) attained and maintained their highest practicable physical well-being. * The facility failed to ensure the insulin injection sites for Residents 16 and 79 were rotated. This failure posed the risk of damaging or causing tissue injuries due to repeated injection sites. * Resident 79 was administered fludrocortisone acetate (medication used to help control the amount of sodium and fluids in the body) when the resident's SBP (systolic blood pressure, the top number of blood pressure that measures the amount of pressure exerted on the vessels when the heart is contracting) was above the parameter prescribed by the physician. [...]
Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure four of 23 final sampled residents (Residents 6, 53, 77, and 79) received appropriate care and treatment to prevent and promote the healing of pressure injuries. The facility failed to turn and reposition Residents 6, 53, 77, and 79 every two hours to meet their care needs. This failure had the potential to worsen or prevent the healing of the residents' pressure injuries.
Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the restorative device was applied to one of 23 final sampled residents (Resident 77). The facility failed to apply the splint on Resident 77's left arm. This posed the risk for Resident 77's left wrist and hand contracture to worsen.
Inspectors wrote2. Review of the facility's P&P titled Smoking revised 8/2017 showed the resident will be assessed by the IDT initially when they verbalize the desire/interest to smoke. The assessment is to determine if the resident is able to smoke safely and not harm themselves or others. The resident's care plan will be updated to address smoking and to include smoking activity and any restrictions, special equipment or instructions required, if any. Residents will not be permitted to keep smoking materials in their possessions unless the interdisciplinary team determines they can manage them safely. Medical record review for Resident 310 was initiated on 4/20/21. Resident 310 was admitted on [DATE]. Review of Resident 310's History and Physical examination dated 4/14/21, showed Resident 310 had the capacity to understand and make decisions. [...]
Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to provide the necessary care and services for the use of GT for one of 23 final sampled residents (Resident 15). * The facility failed to dispose the outdated tube feeding bag and administration kit for Resident 15. This failure posed a risk for complications related to enteral feedings.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary services for respiratory care needs were provided for one of 23 final sampled residents (Resident 20) and one nonsampled resident (Resident 22). * The facility failed to obtain a physician's order for continuous oxygen therapy for Resident 22. Resident 22's continuous oxygen use was not documented in her medical record. * The facility failed to label and date the nasal cannula (thin flexible tube with small prongs inserted into the nostrils) used for oxygen administration for Residents 20 and 22. These failures posed the risk for complications related to respiratory treatment.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate pain management was provided to one of 23 final sampled residents (Resident 84) and one nonsampled resident (Resident 3). * The facility failed to clarify with the physician when there were two different orders for pain scale for Residents 3 and 84. This failure posed the risk of the residents' pain not being managed appropriately.
Inspectors wroteBased on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed to develop and implement the procedures for the provision of pharmaceutical services to meet the needs of the residents as evidenced by: * The facility failed to ensure the controlled medications for Residents 3, 56, and 84 were accurately documented and reconciled in the Medication Administration Record. This posed the risk for diversion of controlled medications and medication administration errors. * The facility failed to replace the facility's emergency kit within 72 hours of opening as per the facility's P&P. This deficient practice posed the potential of an unavailable emergency medication supply. * The facility failed to administer Resident 20's scheduled pain medication as ordered by the physician due to the medication being not available. [...]
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of six unnecessary medication sampled residents (Residents 41 and 23) were not receiving unnecessary medications. * The facility failed to ensure the behavior manifestation and adverse side effects were monitored for Resident 41 related to the use of lorazepam (antianxiety medication). * The facility failed to ensure the adverse side effects were monitored for Resident 23 related to the use of citalopram (antidepressant medication). These failures had the potential for these residents to have adverse complications from their medications.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 23.33%. Two of two licensed nurses (LVN 2 and RN 4) were found to make the medication errors during the medication administration observation. * LVN 2 failed to administer the correct form of vitamin C and multivitamin to Resident 57 as ordered by the physician. * LVN 2 failed to administer the correct dose of selexipag to Resident 20. In addition, LVN 2 failed to administer multivitamins to Resident 20 as ordered by the physician. * RN 4 administered the wrong calcium medication to Resident 78. In addition, RN 4 failed to administer vitamins D2 and D3 to Resident 78 as ordered by the physician. [...]
Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the medications were stored as per the facility's P&P. * The opened Tuberculin PPD vial (purified protein derivative, a multi-dose injectable solution used to determine if a patient has tuberculosis) was not labeled with the open date and was stored in Medication Room A. * The opened Tuberculin PPD vial with an open date past 30 days was stored in Medication Room B. * An emergency kit containing multiple expired medications was stored in Medication Room A. These failures posed the risk of the test not showing an accurate result when determining if a resident had tuberculosis and the potential to result in unsafe administration of medications to the residents.
Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure coordination of hospice services for one of 23 final sampled residents (Resident 32). * The facility failed to show documentation of the current hospice plan of care and certification for Resident 32. In addition, the facility failed to maintain complete documentation of hospice staff visits and services provided for Resident 32. * The facility failed to ensure staff were aware of the individual designated as the facility's hospice coordinator for Resident 32. These failures had the potential to put the resident on hospice services at risk of uncoordinated medical care between the facility and hospice agency.
Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the appropriate infection control practices designed to help prevent the development and transmission of infections were implemented for one of 23 final sampled residents (Resident 16) and for visitors entering the facility. * The facility failed to don the appropriate PPE prior to entering an isolation room and failed to don clean gloves during wound care treatment. * The facility failed to properly screen the visitors for signs and symptoms of COVID-19 prior to entering the facility. These failures posed the risk for transmission of COVID-19 and other disease-causing microorganisms in the facility.
Inspectors wroteBased on observation and interview, the facility failed to provide a sanitary and comfortable homelike environment for the residents and staff. * Resident 20's bathroom was observed with orange brownish stains on the walls and brownish sediments on the floor. * Dead cockroaches and black-colored droppings were observed in Medication Room A.
25 fire safety citations on file: 7 on June 3, 2025, 12 on May 23, 2023, 6 on April 27, 2021.
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) | 4.31 | 4.52 | 3.86 |
| Registered nurses | 0.32 | 0.67 | 0.69 |
| All nursing staff on weekends | 3.95 | 4.09 | 3.42 |
| Nurse aides | 2.71 | ||
| Licensed practical nurses | 1.28 | ||
| Nursing staff turnover (share who left in a year) | 34.8% | 36.7% | 45.8% |
| Registered nurse turnover | 43.8% | 38.1% | 42.9% |
| Administrators who left | 1 |
CMS expects 4.36 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 4.45 on weekdays and 3.95 on weekends, 11% 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 4.63 in April to June 2025 to 4.31 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 | 4.31 | 0.32 | 4.45 | 3.95 | 0.0% | 0 of 90 | 117 |
| Oct to Dec 2025 | 4.28 | 0.32 | 4.43 | 3.88 | 0.0% | 0 of 92 | 118 |
| Jul to Sep 2025 | 4.32 | 0.33 | 4.47 | 3.94 | 0.0% | 0 of 92 | 115 |
| Apr to Jun 2025 | 4.63 | 0.48 | 4.79 | 4.24 | 0.0% | 0 of 91 | 114 |
| 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 | 9.2 | 10.3 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.8 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.6 | 1.2 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.4 | 1.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.0 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 8.1 | 9.8 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 3.7 | 4.3 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 2.1 | 12.0 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 19.0 | 22.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 8.2 | 11.2 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.7 | 2.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.1 | 1.6 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Garden Park Care Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (48.4% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
48.4% this home
No different from 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. 403 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. 347 eligible stays.
12.5% this home
Worse than 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. 232 eligible stays.
67.7% 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. 189 residents counted.
0.6% 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. 333 residents counted.
0.4% 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. 333 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. 8 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: GARDEN PARK CARE CENTER, LLC. CMS links this home to David Johnson, a group of 48 nursing homes averaging 3.3 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Garden Park Care Center, LLC | 5% or greater direct ownership interest | Organization | 100% | 02/01/1995 |
| Dehghanmanesh, Adrian | Corporate officer | Individual | 07/01/2021 | |
| Johnson, Frank | Corporate officer | Individual | 12/09/1994 | |
| Garden Park Care Center, LLC | Operational/managerial control | Organization | 02/01/1995 | |
| Dehghanmanesh, Adrian | Operational/managerial control | Individual | 06/01/2021 | |
| Gunnell, Dean | Operational/managerial control | Individual | 09/01/2022 | |
| Hakim, Asaad | Operational/managerial control | Individual | 11/01/2019 | |
| Joan Goyena, Estrellita | Operational/managerial control | Individual | 03/05/2014 | |
| Johnson, Frank | Operational/managerial control | Individual | 02/01/1995 | |
| Kochek, Joshua | Operational/managerial control | Individual | 04/01/2022 | |
| Oxford, Micheal | Operational/managerial control | Individual | 01/03/2022 | |
| Garden Park Care Center, LLC | Adp of the SNF | Organization | 02/01/1995 | |
| K.h.i.k Co., LLC | Adp of the SNF | Organization | 06/30/2014 | |
| Sun Mar Management Services | Adp of the SNF | Organization | 10/12/1989 | |
| Dehghanmanesh, Adrian | Adp of the SNF | Individual | 06/01/2021 | |
| Farrales, Mary | Adp of the SNF | Individual | 01/01/2023 | |
| Gunnell, Dean | Adp of the SNF | Individual | 09/01/2022 | |
| Hakim, Asaad | Adp of the SNF | Individual | 11/01/2019 | |
| Joan Goyena, Estrellita | Adp of the SNF | Individual | 03/05/2014 | |
| Kochek, Joshua | Adp of the SNF | Individual | 04/01/2022 | |
| Oxford, Micheal | Adp of the SNF | Individual | 01/03/2022 |
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.