Home / California / Los Angeles
3966 Marcasel Ave, Los Angeles, CA 90066 · Los Angeles County · (310) 397-2372
68 certified beds, about 63 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1998
CMS Care Compare ratings, data as of September 1, 2026 · CCN 555726 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on November 1, 2024, inspectors cited 11 health deficiencies (the California average is 15.6, the national average 9.2).
Of 63 health citations since October 2022, 4 were rated as actual harm or immediate jeopardy to residents.
CMS lists 4 fines totaling $96,569 in the last three years; the largest was $35,237, and the latest is dated July 1, 2025.
Nurses and nurse aides worked 4.21 hours per resident per day, against 4.52 across California and 3.86 nationally. Registered nurses accounted for 0.27 of those hours.
CMS links it to Corporate Interface Services, an affiliated group of 40 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 63 health citations on file.
Inspectors wroteBased on interview and record review the facility failed to obtain weight upon admission according to professional standards of practice for one of three sampled residents,(Resident 2). This deficient practice caused the Registered Dietician (RD) to use the most recent general acute care hospital (GACH) weight. This led to an inaccurate baseline weight causing Resident 2 to trigger a weight variance for weight loss and placed Resident 2 at risk for unnecessary weight gain. On 2/27/2026 The California Department of Public Health (CDPH) received a complaint alleging the facility neglects residents nutritional needs. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's written notice of proposed transfer and discharge provided to the resident's responsible party and a copy sent to the office of the state long-term care ombudsman (a representative who assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) at least thirty days prior to proposed discharge date for one of three sampled residents, Resident 1. This deficient practice had resulted in Resident 1 and Resident 1's responsible party feeling harassed and forced to sign a notice of proposed transfer and discharge document on 1/29/2026 for a proposed discharge date on 1/31/2026.
Inspectors wroteBased on interview and record review the facility failed to provide sufficient staffing to maintain supervision for one of four sampled residents (Resident 1) who was identified as a wanderer and a high risk of fall. This deficient practice caused Resident 1 to wander outside onto the patio and sustain an unwitnessed fall leaving a laceration (cut) over Resident 1's left eye that required transport to the general acute care hospital (GACH) where Resident received sutures (a row of stitches holding the edges of a wound together). [...]
Inspectors wroteBased on interview and record reviews for two of three sampled residents, Resident's 1 and 2. The facility failed to prevent a third incident of resident-on-resident altercation. This deficient practice caused Resident 1 to go to Resident 2's new room and provoke a fight which led to Resident 1 hitting Resident 2 on the nose and Resident 2 hitting Resident 1 on the back of the head. Cross Reference: F609.
Inspectors wroteBased on interview and record review for two of three sampled residents, (Resident 1 and 2) the facility failed to report an incident of verbal abuse to the California Department of Public Health (CDPH) and failed to report an incident of physical abuse timely. This deficient practice placed Residents 1 and 2 at risk for further abuse. Cross Reference: F600.
Inspectors wroteBased on interviews and record review, the facility failed to ensure one of three sampled residents (Resident 1) was closely supervised, monitored, and within staff reach to prevent a fall. The facility was aware that Resident 1 is confused (is the inability to think as clearly or quickly as you normally do), has a history of falls, and impulsive behavior (refers to actions that are taken without sufficient thought or consideration of the consequences) of getting up from the wheelchair (WC) without assistance. This deficient practice resulted in Resident 1 falling on 6/24/2025 at 8:30 PM. On 6/24/2025 at 8:30 PM, Resident 1 was transferred to a General Acute Care Hospital (GACH) emergency room (the department of a hospital that provides immediate treatment for acute (sudden onset) illnesses and trauma[injury]) for further evaluation via 911 (emergency response telephone number). [...]
Inspectors wroteCross Referenced F609, F610, F656 Based on interview and record review, the facility staff failed to notify the physician when a resident had a change of condition (CIC) for one of eight sampled residents (Resident 1). This deficient practice had the potential to result in delayed provision of necessary care, treatment and services to Resident 1.
Inspectors wroteCross Referenced F580, F610, F656 Based on interview and record review, the facility failed to implement policies and procedures (P&P) to ensure reporting of a reasonable suspicion of an abuse in accordance with state and federal law for one of eight sampled resident (Resident 1). This resulted in a delay of an onsite inspection by the State Agency (SA) to ensure the safety of the residents and had the potential to result in unidentified abuse in the facility as well as failure to protect residents from any possible abuse.
Inspectors wroteCross Referenced F580, F609, F656 Based on interview and record review, the facility failed to implement its policies and procedures by failing to ensure an investigation was completed for any reasonable suspicion of an abuse in accordance with state and federal law for one of eight sampled resident (Resident 1). This resulted in a delay of an onsite inspection by the State Agency (SA) to ensure the safety of the residents and had the potential to result in unidentified abuse in the facility as well as failure to protect residents from any possible abuse.
Inspectors wroteCross Referenced F580, F609, F610 Based on interview and record review, the facility failed to develop and implement a comprehensive care plan that meet the care/services based on the resident ' s individual assessed needs for one of eight sampled residents (Resident 1) by failing to ensure a care plan was completed when Resident 1 stated to Licensed Vocational Nurse (LVN) 1, that Resident 1 was raped and touched by a Certified Nursing Assistant (CNA). This deficient practice had the potential to result negative impact on Resident 1 ' s health and safety, as well as the quality of care and services received.
Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of the three sampled residents (Resident 4) from verbal abuse by Resident 3 by failing to manage repeated aggressive behaviors by Resident 3. This deficient practice placed Resident 4 and all residents at risk for further abuse.
Inspectors wroteBased on observation, interview, and record review the facility failed to investigate a residents complaint allegation and make prompt efforts to resolve the resident ' s grievance for one of three sampled residents, Resident 1. This deficient practice resulted in inadequate available incontinent briefs in Resident 1 ' s size which the facility does not carry/stock.
Inspectors wroteBased on observation, interview and record review the facility failed to keep Hospice (compassionate care for people who are near the end of life provided at the person ' s home or within a health care facility) visit records for one of two sampled residents on Hospice, Resident 1. This deficient practice was not in line with the facility's policy and had the potential for nursing staff not be be informed of any changes recommended by the hospice staff for Resident 1.
Inspectors wroteBased on observation, interview, and record review, for one of three sampled residents (Resident 1), facility failed to: 1. Adequately monitor and supervise Resident 1 to prevent elopement (to leave a health care or educational facility without permission or authorization) according to the facility ' s policy and procedures (P&P), titled, Wandering and Elopement, dated 2/10/2023 2. Ensure alarm system was in place on two of seven exit doors to alert staff if a resident was eloping and or exiting the facility. 3. Ensure the front desk was monitored daily from 7:30 P.M., to 8 A.M., These deficient practices resulted in Resident 1 eloping from the facility on 11/22/2024 at 3:45 A.M., placing the resident at increased risk for extreme weather, medical emergencies, accidents, injuries, hospitalization, and/or death.
Inspectors wroteBased on observation, interview, and record review the Licensed Vocational Nurse (LVN) 1 failed to replace missing Lidocaine patch (medication applied to skin for pain) for one of three sampled residents, Resident 1 Failed to replace missing Florastor (probiotic supplement for the gut) for one of three sampled residents, Resident 3. These deficient practices caused LVN 1 to borrow the Lidocaine patch from Resident 2 which placed Resident 2 at risk of not having enough Lidocaine patches available when needed and caused Resident 3 to miss a scheduled dose.
Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Remove expired Glucose Quality Control Solution from medication cart A. 2. Place expired Glucose Quality Control Solution in the correct original package/box. These failures had the potential to cause confusion amongst staff and inaccurate blood sugar results to the residents in the facility.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Food was stored in a sanitary manner to prevent growth of microorganisms (germs) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food), as well as toxins for one of 14 residents (Resident 29). 2. Outside food brought in for the residents' stored in the residents' assigned refrigerator was discarded after 48 hours. 3. The residents' refrigertaor remained locked at all times. 4. Dented and expired canned food in the kitchen, are not stored in the same food storage room with and next to canned food ready to use for the residents. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's right to be treated with dignity was maintained by not providing a dignity bag cover (a bag used to maintain a person's mobility, dignity, and comfort) for one out 14 sampled residents (Resident 46) This deficient practice has the potential to affect resident's sense of self-worth and self-esteem for Resident 46.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were not left with the resident who was not capable of self-administering oral medications for one of 14 sample residents (Resident 29). This deficient practice had the potential to result in unauthorized/unintended person accessing/using the medications with the potential for harm through drug interactions and/or allergic reactions resulting in unnecessary hospitalizations and even death.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the catheter drainage (a bag that collects urine that drains from a catheter) bag for two of 26 sampled residents (Resident 46 and Resident 50) were placed inside a dignity bag. This deficient practice resulted in violation of Resident 46 and Resident 50's right to have dignity.
Inspectors wroteBased on observation, and interview, the facility failed to ensure a quiet, comfortable, and homelike environment for two of six sampled residents. Residents 48 and 210. This failure resulted in residents not being able to fall asleep or remain asleep throughout the night. In addition to residents not being able to rest peacefully throughout the day in a homelike environment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents' (Resident 27) Preadmission Screening and Resident Review (PASRR - a screening evaluation used to determine whether placement in a long term care facility is appropriate for the resident) Level II (a person-centered evaluation that helps determine placement and specialized services) assessment was completed as required by PASRR Level I (a tool that helps identify possible serious mental illness and/or intellectual/development disability) assessment. This deficient practice placed Resident 27 at risk for not receiving the necessary care and specialized services tailored to Resident 27's needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 15) by failing to: 1) Identify Resident 15's indwelling catheter (a thin, hollow tube that's inserted into the bladder to drain urine) had yellow cloudy fluid with sediments. 2) Change Resident 15's indwelling catheter bag according to the physician's order and facility's policy and procedures titled Care of Catheter revised on 6/10/2021. These deficient practices placed Resident 15 at increased risk for urinary tract infection (UTI-is an infection in any part of the urinary system).
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 16 sampled residents (Residents 7 and 2) by failing to ensure: 1. Resident 7 received the correct amouunt of prescribed (ordered) volume of oxygen (a colorless, odorless gas that is essential for life and the proper functioning of the body) as ordered by the physician. This deficient practice resulted in Resident 7 receiving no oxygen per physician order and had the potential to negatively impact the Resident 7's health and well-being. 2. Resident 2 received two liters (unit of measure) of continuous oxygen as oredered by the physician. This deficient practice had the potential to cause complications associated with oxygen therapy.
Inspectors wroteBased on interview and record review, the facility failed to complete performance evaluations annually for one out of five sampled staff. This deficient practice had the potential for residents to not receive the appropriate level of care needed affecting quality of care and potentially leading to resident harm.
Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control measure for two of ten sampled residents (Resident 2 and Resident 50) by failing to ensure that:, 1. Resident 2's nasal cannula (a medical device that provides supplemental oxygen to the patient through two prongs that fit into the nostrils) tubing was not touching the floor. 2. Resident 2's oxygen (gas that is essential for life on earth) humidifier (a device that adds moisture to the air to prevent dryness) was changed after seven days per facility's policy. 3. Resident 50's supra pubic catheter (a thin tube that drains urine from the bladder through a small cut made in the lower abdomen [part of the body located between the chest and the hips]) drainage bag was not touching the floor. These deficient practices had the potential to result in infections for Resident 2 and Resident 50.
Inspectors wroteBased on interview, and record review, the facility failed to ensure the Assistant Director of Nursing (ADON) and licensed vocation nurse had the skill set to train the registered nursing staff regarding resident care and resident assessment. This deficient practice resulted in or had the potential to result in unsatisfactory training for the registered nursing staff.
Inspectors wroteBased on interview, and record review, the facility failed to ensure the Director of Staff and Development (DSD)had the specific competencies and skill sets necessary to plan, implement, direct, and evaluate the facility ' s educational programs for all employees by failing to acquire the continuing education course required to be a DSD. This deficient practice placed all employees in the facility at risk for not receiving educational provisions that a DSD is generally responsible for.
Inspectors wroteBased on interviews, and record review the facility ' s governing body (individuals such as facility owner(s), Chief Executive Officer(s), or other individuals who are legally responsible to establish and implement policies regarding the management and operations of the facility) failed to ensure the Administrator (ADM) who was responsible for managing and overseeing the implementation of policies and procedures reported the change in Administrator as required by State and Federal regulations. This deficient practice had the potential to affect the safety and over all well-being of 56 out of 56 residents and had the potential to result in poor management of the facility.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of her individuality for one of four sampled residents (Resident 1) by failing to provide a timely lunch tray as indicated on the facility ' s meal schedule. The deficient practice resulted in Resident 1 feeling irritable and uncomfortable due to hunger.
Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 4) was monitored and supervised to prevent fall and injuries as evidenced by failing to: 1. Ensure Resident 4's bed was in low position based on Resident 4's fall care plan and physician order. 2. Ensure Resident 4 had floor mats based on Resident 4's fall care plan and physician order. 3. Ensure Resident 4 was not left unattended by Certified Nursing Assistant 4 (CNA 4) while the bed was in high position , and the bed rails (also called side rails; are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one- quarter, or one-eighth lengths) are in position (on). [...]
Inspectors wroteBased on interview and record review, the facility failed to check/monitor for resident's safety every two hours around the clock in accordance with facility's policy and procedures, titled, Resident Safety, for one of three sampled residents (Resident 1). Resident 1 was at risk for fall. This deficient practice had the potential not to identify circumstances that pose a risk for the safety and wellbeing of Resident 1.
Inspectors wroteBased on interview and record review, facility failed to document an acute change of condition in one out of three residents medical Record, Resident 1. This deficient practice led to incomplete documentation of Resident 1 ' s Healthcare Record and had the potential to cause inaccuracies in communication of, and dissemination of vital medical information to Resident 1 ' s healthcare team regarding Resident1 ' s medical condition, leading delay in care and resulting in poor outcomes and even death.
Inspectors wroteBased on interview, and record review, the facility failed to provide a minimum of 3.5 nursing hours per patient day (NHPPD) on two (2) out of 14 sampled days and a minimum of 2.4 Certified Nursing Assistant (CNA) NHPPD on six (6) out of 14 sampled days in accordance with the facility's policy and State requirement. This deficient practice had a potential to violate residents' rights in receiving the required nursing hours, placing the residents at risk for inadequate care and safety.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) provide care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of two sampled residents (Resident 1), who was assessed at risk for fall by failing to: 1. Ensure Certified Nurse Assistant 1 (CNA 1) provided two-person physical assistance (had help from another staff member) when turning Resident 1 in bed as indicated in Resident 1's Minimum Data Set (MDS- a required standardized assessment and care planning tool) dated 12/20/2023. 2. [...]
Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the State Survey Agency within twenty-four hours for one of three sampled residents (Resident 1). This deficient practice resulted to a delay of an onsite inspection by the State Survey Agency to ensure Resident 1's allegation of abuse was investigated.
Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and treatment for urinary tract infection (UTI, an infection in the drainage system for removing urine) due to failure to promptly (with little or no delay) notify a physician and or a nurse practitioner (NP - a nurse with a graduate degree in advanced practice nursing) of a urinalysis (UA - urine test used to check for infection or kidney problems) test results positive for bacteria on [DATE] and failure to place an order for urine culture and sensitivity (C&S -a test to diagnose germs such as bacteria or fungus [yeast or mold] that can cause an infection and checks on the appropriate medicine, such as an antibiotic [medication to treat infection]) for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedures (P&P) titled, Laboratory -Critical values (laboratory [...]
Inspectors wroteBased on interview and record review, the facility failed to provide medical records requested upon written request for one of three sampled residents (Resident 1). This deficient practice violated the rights of Resident 1's representative to obtain copy of the medical records.
Inspectors wroteBased one interview and record review, the facility failed to provide necessary care and treatment for urinary tract infection (UTI, an infection in the drainage system for removing urine) due to failure to promptly (with little or no delay) notify a physician and or a nurse practitioner (NP - a nurse with a graduate degree in advanced practice nursing) of a urinalysis (UA - urine test used to check for infection or kidney problems) test results positive for bacteria on [DATE] and failure to place an order for urine culture and sensitivity (C&S -a test to diagnose germs such as bacteria or fungus [yeast or mold] that can cause an infection and checks on the appropriate medicine, such as an antibiotic [medication to treat infection]) for one of three sampled residents (Resident 1) in accordance with the facility ' s policy and procedures (P&P) titled, Laboratory -Critical values [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to provide care in a manner that promoted or enhanced residents dignity and respect for four of four sampled residents (Residents 29, 33, 64 and 121) the facility's policy and procedures titled, Catheter-Care of dated 6/10/2021, by failing to: 1. Ensure facility staff practiced and promoted good attitude and behavior towards Residents 29 and 121 in accordance with the facility's policy and procedures titled, Resident Right dated 1/1/2012. 2. Ensure the Resident's urinary collection bag was covered with a privacy bag for Residents 33 and 64 in accordance with the facility's policy and procedures titled, Catheter-Care of dated 6/10/2021. These deficient practices had the potential to cause psychosocial harm and violated the resident's rights to be treated with dignity for Residents 29, 33, 64 and 121.
Inspectors wroteBased on interview and record review, the facility failed to ensure there was sufficient nursing staff available at all times to provide nursing and related services to meet the resident's needs for seven of 22 sampled residents (Resident 29, 33, 39, 40, 41, 121 and 122) in accordance with the facility's policy and procedures titled, Nursing Department-Staffing, Scheduling & Postings dated 7/2018. This deficient practice resulted in call lights not being answered in a timely manner, residents not receiving assistance from staff with activities of daily living (ADLs-bed mobility, walk in room/corridor, transfer, toilet use, bathing, personal hygiene, etc.) in a timely manner and had the potential to affect the quality of life, quality of care and treatment of residents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment for 3 of 3 sampled residents (Residents 3, 121 and 172) in accordance with the facility's policies and procedures titled, Resident Isolation-Initiating Transmission Based-Precautions dated 4/22/2016, and Cleaning & Disinfection of Resident Care Equipment dated 01/01/2012, by failing to: 1. Ensure a multi-use pill cutter was cleaned before and after use when cutting medication tablet that require a half dose for Resident 3 and a multi-use blood pressure cuff was sanitized between use for Resident 3 and Resident 172. 2. Ensure Resident 121, who tested positive for ESBL (Extended spectrum beta-lactamase bacteria that can't be killed by many of the antibiotics treat infections. [...]
Inspectors wroteBased on interview and record review, the facility failed to transmit to Medicare and Medicaid Services (a Federal agency that administers the nation's major healthcare programs, including Medicare and Medicaid) within 14 days, the quarter and annual completed Minimum Data Set (MDS- standardized assessment and care screening tool) Assessments for five of five sampled residents (Residents 9, 11, 41, 48 and 51). This deficient practice resulted in more than 14 days delay of transmission to Medicare and Medicaid Services, the clinical assessment for Residents 9, 11, 41, 48 and 51.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow through with the Preadmission Screening and Resident Review (PASRR) recommendation to obtain a PASRR level II evaluation for two of three sampled residents (Resident 21 and 28) in accordance with the facility's policy and procedures titled Pre-admission Screening Level II Resident Review revised 9/2017. This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Residents 21 and 28.
Inspectors wroteBased on interview, and record review, the facility failed to formulate care plan with measurable objectives, timeframes, and interventions to meet the needs of four of 22 sampled residents (Residents 47, 48, 64 and 221) in accordance with the facility's policy and procedure titled, Comprehensive Person-Centered Care Planning dated 11/2018, The fcaility was aware that: a) Resident 47 did not have teeth. b) Resident 48 had diagnosis of post-traumatic stress syndrome (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a tarrying event). c) Resident 64 was on oxygen (O2- colorless, odorless, tasteless gas necessaru to sustain life) therapy. d) Resident 221 had bowel (gut) and bladder (balloon like organ that collects urine in the body) concerns. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to provide services to maintain and/or improve resident's (Resident 121) bladder function when a urinal was not offered per the resident's request in accordance with the facility's policy and procedures titled, Bowel and Bladder Training/Toileting Program dated 8/21/2023. The deficient practice resulted in Resident 121 being unable to access the urinal and having to void in bed.
Inspectors wroteBased on observation and interview the facility failed to maintain a sanitary condition in handling dishes to prevent food contamination and the growth of disease in accordance with facility's policy and procedures titled Dietary Department -Infection Control for Dietary Employees, revised 11/9/2016,when: 1. Dietary Supervisor (DS) handled clean dishes from the dishwasher with street clothes on without an apron. 2. Dietary Aid (DA) handled dirty dishes and then proceeded to handing clean dishes from the dishwasher without observing hand hygiene and putting on a clean apron. This deficient practice had the potential to place 69 of 69 residents, who consumed food prepared by the facility kitchen, at risk for food borne illness.
Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of one of four sampled residents (Resident 3) by failing to ensure Resident 3 ' s medication was dispensed as written. This deficient practice had the potential for Resident 3 to receive a lesser dose than prescribed by the physician.
Inspectors wroteBased on interview and record review, the facility failed to follow its policy on Medication Administration on 2 of 4 sampled residents (Resident 2 and 3) as evidenced by: 1. Failing to ensure Resident 2 ' s pain medication (oxycodone - a controlled narcotic analgesic medication that treats moderate to severe pain) was available for administration. 2. Failing to ensure that the administration of Resident 2 ' s oxycodone was documented in the medication administration record (MAR) 3. Failing to administer enoxaparin (an anticoagulant; a medication used to help prevent the formation of blood clots) as ordered by the physician and as indicated in the care plan for Resident 3. 4. Failing to ensure Resident 3 ' s enoxaparin was transcribed with the correct route to the MAR. [...]
Inspectors wroteBased on observation, interview, and record review, the nursing staff failed to ensure call lights were within reach for eight of 40 sampled residents (Residents 10, 11, 12, 14, 18, 22, 56 and 114). These deficient practices had the potential to result in the residents not being able to summon staff for assistance for care and services as needed, which could lead to accidents such as falls with injuries.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the appropriate setting of the low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) was properly set up for five of five sampled residents (Residents 4, 7, 21, 28, and 112) according to settings that were consistent with manufacturer's guide and individualized care plan for six of six sampled residents. These deficient practices placed Residents 4, 7, 21, 28, and 112 at risk to develop a pressure injury (bed sore-localized damage to the skin and or underlying soft tissue over bony prominence) or at risk of poor wound healing of the current pressure ulcer.
Inspectors wroteBased on interview and record review, the facility failed to ensure there was sufficient nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physically, mental and psychosocial well-being for six of 40 sampled residents (Residents 10, 45, 47, 59, 60 and 114). This deficient practice resulted in call lights not being answered in a timely manner; residents not receiving assistance from staff with activities of daily living (ADLs-bed mobility, walk in room/ corridor, transfer, toilet use, bathing, personal hygiene, etc.) in a timely manner and had the potential to affect the quality of life and treatment for Residents 10, 45, 47, 59, 60 and 114.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing information posted was correct, updated with the actual hours daily per facility policy on three of three sampled days (10/3/2022, 10/4/2022 and 10/5/2022). As a result, the accurate and final Direct Care Services Hours Per Patient Day (DHPPD) was not readily accessible to the residents and visitors per facility policy.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the correct type of insulin (used to control the level of the sugar-glucose in the blood) was administered, according to a sliding scale (a dosing regimen that prescribes how much insulin to give for different levels of blood sugar) as ordered, to one of five sampled residents (Resident 23) This deficient practice had placed the resident at risk of inadequate blood sugar management, which could cause hypoglycemia (low blood sugar), a potential to lead to other health complications including coma and death.
Inspectors wroteBased on observation, interview, and record review, the facility failed to: A. Ensure that two unopened insulin (used to lower blood sugar) medications were stored in the refrigerator, in two of three medication carts affecting Resident 9 and 15. B. Remove five expired Jevity 1.2 Cal (used to provide complete, balanced nutrition for tube feeding residents) cartons from one of three medication carts affecting all residents receiving this nutritional supplement. C. Ensure medication cart was locked at all times per facility policy. These deficient practices resulted in unsafe storage of the medications and had the potential to result in medication errors leading to health complications including hospitalization or death.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service when: 1. The refrigerator log was not being fully checked by kitchen staff. 2. The salt was stored in a container with the incorrect open and use-by date. These deficient practices may have the potential to cause food borne illness to residents who received food from the facility's kitchen.
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control and prevention program by failing to: 1. Ensure 1 of 1 sampled facility staff (Licensed Vocational Nurse 3-LVN 3) wore full personal protective equipment (PPE-mask, gown, eye protection, gloves) before entering Resident 26 and 32's room in yellow zone (area in the facility for residents under investigation for possible COVID-19 infection) per facility policy. 2. Ensure Resident 7's oxygen concentrator (portable medical device that provides oxygen) was maintained clean and in sanitary condition by not leaving any uncleaned towels, plastic bag and opened shampoo bottles on top. These deficient practices had the potential to result in the spread of disease and infection to residents and staff.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that promoted or enhanced resident's dignity and respect for two of two sampled residents (Residents 1 and 119) by failing to ensure facility staff promote good attitude and behavior toward the residents per facility's policy. This deficient practice had the potential to cause psychosocial harm to the residents and can violate resident's right to be treated with dignity.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents' medical records were updated to indicate that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or responsible parties for one of one sampled resident (Resident 26). This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate advanced directives and had the potential to cause conflict with health care wishes for Resident 26.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure protection of resident's medical record for one of one sampled resident (Resident 47). This deficient practice had the potential to violate Resident 47's right to privacy and confidentiality.
Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of quality for one of 19 sampled residents (Resident 24) by failing to ensure that Resident 24's medication was not left unattended at the bedside. This deficient practice had the potential of placing Resident 24 at risk of receiving the wrong medications and for another resident to consume the medications not met for them.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident receives appropriate treatment and services to increase, prevent, or maintain the range of motion (ROM- the extent of movement of a joint) mobility for one of 19 sampled resident (Resident 1). This deficient practice had the potential to place Resident 1 at risk for further ROM decline and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received adequate supervision while smoking cigarettes, and cigarettes and or medication were not left unattended at the bedside for two of 40 sampled residents (Resident 24 and 54). These deficient practices increased the risk for injuries, accidents, fires in the facility, and increased the risk for medication diversion and medication ingestion by unintended person.
32 fire safety citations on file: 5 on November 1, 2024, 17 on October 6, 2023, 10 on October 5, 2022.
| Date | Penalty | Amount or length |
|---|---|---|
| July 1, 2025 | Fine | $17,852 |
| June 5, 2024 | Fine | $33,248 |
| February 2, 2024 | Fine | $10,232 |
| September 26, 2023 | Fine | $35,237 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
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) | 4.21 | 4.52 | 3.86 |
| Registered nurses | 0.27 | 0.67 | 0.69 |
| All nursing staff on weekends | 3.86 | 4.09 | 3.42 |
| Nurse aides | 2.71 | ||
| Licensed practical nurses | 1.23 | ||
| Nursing staff turnover (share who left in a year) | not reported | 36.7% | 45.8% |
| Registered nurse turnover | not reported | 38.1% | 42.9% |
| Administrators who left | not reported |
CMS expects 4.43 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 4.36 on weekdays and 3.86 on weekends, 11% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.5% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.09 in April to June 2025 to 4.22 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 | 4.22 | 0.27 | 4.36 | 3.86 | 0.5% | 0 of 90 | 63 |
| Jul to Sep 2025 | 4.30 | 0.27 | 4.44 | 3.95 | 3.2% | 1 of 92 | 63 |
| Apr to Jun 2025 | 4.09 | 0.38 | 4.24 | 3.72 | 0.2% | 0 of 91 | 65 |
| 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 | 13.4 | 10.3 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.3 | 0.8 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.5 | 1.2 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.8 | 1.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.7 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 13.7 | 9.8 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 6.8 | 4.3 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 4.3 | 12.0 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 29.2 | 22.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 7.5 | 11.2 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 3.6 | 2.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.9 | 1.6 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Mar Vista Country Villa Healthcare & Wellness's Medicare short-stay residents. On returning residents home or to the community, CMS rates it worse than the national rate (42.7% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
42.7% this home
Worse 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. 130 eligible stays.
11.3% 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. 134 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. 121 eligible stays.
48.8% this home
Median of homes: California59.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 80 residents counted.
1.5% 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. 137 residents counted.
0.0% 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. 137 residents counted.
92.0% 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. 25 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: MAR VISTA COUNTRY VILLA HEALTHCARE & WELLNESS CENTRE LP. CMS links this home to Corporate Interface Services, a group of 40 nursing homes averaging 2.5 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Corporate Interface Services LLC | Operational/managerial control | Organization | 03/18/2024 | |
| Rockport Administrative Services, LLC | Operational/managerial control | Organization | 10/31/2014 | |
| Banafshe, Paymon | Operational/managerial control | Individual | 01/01/2024 | |
| Goldstein, Shmuel | Operational/managerial control | Individual | 10/16/2023 | |
| Mar Vista Wellness Gp LLC | General partnership interest | Organization | 08/01/2014 | |
| Rechnitz, Shlomo | Limited partnership interest | Individual | 08/01/2014 | |
| Corporate Interface Services LLC | Adp of the SNF | Organization | 05/15/2025 | |
| Mar Vista-Let LLC | Adp of the SNF | Organization | 04/03/2025 | |
| Rockport Administrative Services, LLC | Adp of the SNF | Organization | 05/15/2025 | |
| Banafshe, Paymon | Adp of the SNF | Individual | 01/01/2024 | |
| Goldstein, Shmuel | Adp of the SNF | Individual | 10/16/2023 |
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.
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