Home / California / Los Angeles
2411 W. Temple Street, Los Angeles, CA 90026 · Los Angeles County · (213) 380-3210
99 certified beds, about 94 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1976
CMS Care Compare ratings, data as of September 1, 2026 · CCN 555019 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on May 29, 2026, inspectors cited 9 health deficiencies (the California average is 15.6, the national average 9.2).
Of 61 health citations since November 2023, 1 was rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 1 fine totaling $144,964 in the last three years; the largest was $144,964, and the latest is dated July 15, 2024.
Nurses and nurse aides worked 4.81 hours per resident per day, against 4.52 across California and 3.86 nationally. Registered nurses accounted for 0.36 of those hours.
32.7% of nursing staff left within the year CMS measured (California average 36.7%).
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 61 health citations on file.
Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was readmitted to the facility following hospital discharge when the resident's needs could be met by the facility. This failure resulted in Resident 1 remaining hospitalized for an additional day after the hospital physician determined the resident was medically stable for discharge, potentially violating Resident 1's rights to return the facility after hospitalization. During a record review of Resident 1's Transfer Record from the facility, dated 6/8/2026, the Transfer Record indicated Resident 1 was sent to a general acute care hospital (GACH 1) on 6/8/2026 due to low hemoglobin (an iron-rich protein found in red blood cells that carries oxygen from the lungs to the rest of the body, and transports carbon dioxide back to the lungs). [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled Residents (Resident 1), Resident 1 who was assessed as high risk for falls, received adequate supervision and fall prevention interventions to prevent repeated falls on 5/31/2026 and 6/1/2026 by failing to: 1. Reevaluate the resident's fall risk or determine whether current fall prevention interventions required modification following the fall on 5/31/2026 at approximately 11 PM. 2. Update the resident's care plan or implement additional interventions prior to the second fall occurring on 6/1/2026 at approximately 3 -4 AM. As a result, Resident 1 experienced a second fall and sustained injuries to the right eye and right knee requiring hospital evaluation. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure medication dispositions (the processes that dictate how a drug moves through) were done by a licensed nurse and another as witness by failing to: -Ensure there was documentation of the witnesses' signatures. This failure had the potential of misuse, or improper storage, of medications.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to follow sanitary food and water safety practices and food preparation practices by failing to ensure: -The kitchen staff (in general) labeled an opened yogurt container in the reach-in refrigerator with an open date or use by date. - Two of three cutting boards in the dry food preparation area did not have deep knife marks. -To label the facility's emergency portable water (safe to drink for human consumption) reserves for 13 of 13 five-gallon water containers in the kitchen storage. [...]
Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical records for one of two sampled residents (Resident 84) by failing to:- Ensure the licensed nurses (in general) completed the documentations when Resident 84 returned from hemodialysis (HD-a life-sustaining treatment for kidney failure that acts as an artificial kidney, filtering waste, toxins and excess water from the person's body using a machine) appointments. This failure placed Resident 84 at risk of not receiving appropriate care due to inaccurate medical care information and the potential to result in confusion in the care and services provided to Resident 84.
Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the care plan for one of two sampled residents (Resident 12) by failing to:-Ensure Resident 12's care plan addressed Resident 12's skin wound treatment. This failure had the potential to affect Resident 12's skin wound care and treatment.
Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of practice (the everyday rules and behaviors that keep patients safe and ensure high-quality healthcare) for one of five sampled residents (Resident 5) by failing to:-Ensure licensed nurses (in general) rotated the subcutaneous injection (SQ-insertion of medications beneath or under the layers of the skin) sites during medication administration (the process of giving medicine to a resident) of Resident 5's insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) medication. This failure had the potential to cause Resident 5 to have skin breakdown, bruising, lipohypertrophy (lump of fatty tissues under the skin), and/or medication malabsorption (inability to be distributed through the bloodstream to various tissue of the body).
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the correct Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure ulcers [localized damage to the skin and/or underlying tissue usually over a bony prominence]) settings for one of three sampled residents (Resident 92) who had a stage 3 pressure ulcer (Full thickness loss of skin. Dead and black tissue may be visible) to the left buttock. This failure had the potential to place Resident 92 at risk for further skin breakdown and lead to the worsening of Resident 92's stage 3 pressure ulcer.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to clarify the physician's order for Meropenem (type of antibiotic, medication used to treat bacterial infections) intravenous IV (administering medication directly into the blood stream through a vein using a needle) for one of one sampled resident (Resident 77). This failure had the potential for Resident 77 to receive an increased amount of Meropenem which could lead to toxicity (a degree to which a substance can injure or poison a person), adverse side effects (any unintended, harmful, or undesirable effect of a medication), and kidney injury (a decline in kidney function).
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure severe drug-to-drug interaction (occurs when taking two or more medications together causes unexpected, dangerous, or life-threatening reactions) were reviewed and acted upon for one (1) of 3 sampled residents (Resident 82). When on 5/27/2026 Resident 82's Biktarvy (a 3 in 1 antiviral medication used to treat Human Immunodeficiency Virus, HIV, a virus that attacks the body's immune system by destroying white blood cells) 50/200/25 milligrams (mg, unit to measure a dose) was administered with one count of Ferrous Sulfate (an iron supplement) 325 mg, and one count of magnesium oxide (a magnesium supplement) 400 mg, despite having a severe interaction alert documented in the resident's electronic health record. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that dental services were provided to one of two sampled residents (Resident 24) reviewed for dental services by failing to: -Ensure to schedule Resident 24's dental consultation and treatment in accordance with the facility's policy and procedure titled Dental, Vision, and Hearing Evaluations. This failure had the potential to negatively affect Resident 24's oral health and ability to chew food.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a significant change in condition was promptly reported to licensed nursing staff for one of three residents reviewed (Resident 2), when Certified Nursing Assistant 1 (CNA) did not report a resident's cough on 4/11/2026 for approximately four (4) days. This failure had the potential to delay assessment, diagnosis, and treatment, placing Resident 2 at risk for worsening condition. During a review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of acute bronchitis (the temporary inflammation of the airways in the lungs, typically caused by viruses), and Chronic Obstructive Pulmonary Disorder (COPD -lung disease causing restricted airflow and breathing problems). [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) had a comprehensive care plan that was timely revised, consistently documented, and readily accessible to staff following a significant change in condition requiring hospitalization on 1/27/2026. This failure resulted in Resident 2 lacking a Care Plan listing goals and interventions to address her diagnosis of acute bronchitis (the temporary inflammation of the airways in the lungs, typically caused by viruses) on 1/27/2026 and had the potential to impact the coordination of care and Resident 2's health outcomes. During a review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of acute bronchitis (the temporary inflammation of the airways in the lungs, typically caused by viruses). [...]
Inspectors wroteBased on interview and record review the facility failed to ensure administration of medication was documented for one of three sampled residents (Resident 1). For Resident 1, the facility failed to document when Resident 1 was given Benadryl (medication used to relieve symptoms of allergies) 25 milligrams (mg., metric unit of measurement, used for medication dosage and/or amount) orally on 9/18/25. This deficient practice had the potential for medication error and medication duplication to Resident 1. During a review of the admission Record, indicated the facility admitted Resident 1 on 1/31/25 and re-admitted on [DATE] with diagnoses including generalized muscle weakness, hypertension (high blood pressure) and dementia (a group of thinking and social symptoms that interferes with daily functioning). [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician order before administering a medication to one of three sampled residents (Resident 1). For Resident 1 the facility failed to:1. Obtain a physician order prior to the administration of Benadryl tablet (medication used to relieve symptoms of allergies) 25 milligrams (mg., metric unit of measurement, used for medication dosage and/or amount) orally.2. Ensure the Benadryl 25 mg. tablet was not left at Resident 1's bedside table unattended. These deficient practices had the potential to result in harm to Resident 1 and other residents from inappropriate and unsafe medication administration. [...]
Inspectors wroteBased on interview and record review the facility failed to administer medication as ordered by the physician for one of four sampled residents (Resident 1). For Resident 1, the facility failed to administer the metronidazole (antibiotic that treats infection) 500 milligrams (mg., metric unit of measurement, used for medication dosage and/or amount) as ordered by the physician. This deficient practice resulted in Resident 1 not given one dose of the metronidazole 500 mg. and had the potential for Resident 1's infection to worsen. During a review of the admission Record indicated the facility admitted Resident 1 on 1/30/25 with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and pressure ulcer (wounds that occur from prolonged pressure on the skin) of the sacral region (lower back). [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were kept secure in accordance with professional standards of practice for one of four sample residents (Resident 2). During medication pass observation on 7/22/25 at 9 a.m., the facility failed to ensure Resident 2's medications were not left on top of the medication cart while the medication cart was left unattended. This deficient practice had the potential for other residents and other individuals to easily access the medications on top of the cart for their own. use. During a review of the admission Record indicated the facility admitted Resident 2 on 8/2/23 and readmitted on [DATE] with diagnoses including pneumonia (an infection/inflammation in the lungs) and generalized muscle weakness. [...]
Inspectors wroteBased on interview and record review the facility failed to implement the care plan for one of three sampled residents (Resident 1). For Resident 1, the facility failed to assess and document weekly Resident 1 ' s moisture associated skin damage (MASD, moisture associated skin damage caused from prolonged exposure to moisture) to the buttocks area as indicated in Resident 1 ' s care plan. This deficient practice resulted in not being able to determine if Resident 1 ' s MASD had healed before Resident 1 was discharged from the facility on 4/11/25.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the environment is free of hazard for one of three sampled residents (Resident 3). During observation on 5/13/25, the facility hall was lined with linen carts, dirty linen hampers, trash hampers and showers chairs on both sides of the hall. Residents 3 stated it was difficult for him to self-propel his wheelchair due to the clutter in the hallway. This deficient practice had the potential for accidents to occur for Resident 3 and other residents.
Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled Residents (Resident 19) had an advance directive (a legal document indicating resident preference on end-of-life treatment decisions). This failure violated Resident 19 and/or representative's rights to be fully informed of the option to formulate an advanced directive and had the potential not to follow Resident 19's wishes.
Inspectors wroteBased on interview and record review, the facility failed to notify the State Long Term Care Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) when the facility transferred one of two sampled residents (Resident 53) to the General Acute Care Hospital (GACH). This failure had the potential for Resident 53 not to have a representative.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure to implement the care plan for one of 19 sampled resident (Resident 92) for the use of a hand mitten (used to help protect residents who are prone to disrupting medical treatment). This failure had the potential to cause a lack of monitoring for Resident 93's skin integrity and circulation.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to maintain good hygiene for one of one sampled residents (Resident 68). This failure had the potential to expose Resident 68 to skin irritation, skin breakdown, and possible infection.
Inspectors wroteBased on interview and record review, the facility failed to administer insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) according to the facility's policy by failing to rotate the administration site when administering insulin to one of one sampled residents (Resident 4). This failure had the potential for Resident 4 to experience skin complications.
Inspectors wroteBased on interview and record review the facility failed to ensure Treatment Nurse 1 (TN1) monitored the progression of the pressure ulcers (pressure injury, localized damage to the skin and/or underlying tissue usually over a bony prominence) for one of one sampled residents (Resident 53). This failure had the potential for Resident 53's pressure ulcers to worsen.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure not to leave a lighter unattended (left alone without supervision) and unsecured (unprotected) at a resident's bedside table for one of two sampled residents (Resident 55). This failure had the potential Resident 24 to sustain burns and/or cause a fire.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary respiratory care services for one of two sampled residents (Resident 78), by failing to ensure Resident 78 who was receiving oxygen through a nasal cannula tubing (device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help) was not wrapped around a trash can while Resident 78 used the nasal cannula. This failure had the potential for Resident 78 to experience respiratory infections (infections of parts of the body involved in breathing) associated with using an unsanitary (dirty, unhealthy, or unclean in a way that could endanger health) nasal cannula tubing.
Inspectors wroteBased on interview and record review the facility failed to document and monitor for manifestations of behavior (how a person's personality or inner state is expressed through their outward actions and reactions) for one of five sampled residents (Resident 3) who was taking Aripiprazole (Abilify, a medication known as an antipsychotic medication used to treat and manage schizophrenia [a disorder that affects a person's ability to think, feel, and behave clearly]). This failure had the potential for Resident 3 to take unnecessary medication.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two opened insulin pens (a device used to administer insulin, a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) were discarded per facility's policy. This failure had the potential for the medication dispensing errors.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) for one of three residents (Resident 2's) right hand swelling noted on 1/5/25. This failure had the potential to negatively affect the delivery of care and services.
Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 2) was offered a substitute meal as required if the resident consumed less than 50% of the meal. This deficient practice had the potential to result in malnutrition, dehydration, and overall decline in health and medical condition.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide mouthcare regularly for one of three sampled residents (Resident 1). During observation on 12/30/24 at 10 a.m., Resident 1 was observed with creamy substance at the corner of the left mouth, tongue was coated with white crust and the lower lip was dry with crusts. This deficient practice had the potential for Resident 1 to suffer from pain and infection.
Inspectors wroteBased on interview and record review the facility failed to ensure the records for residents were complete and accurate for one of three sampled residents (Resident 1). For Resident 1, the facility failed to ensure the fluid and oral intake were accurately documented on 12/15/24,12/16/24, 12/17/24 and 12/29/24. This deficient practice resulted in failing to determine the oral and fluid intake of Resident 1.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of Coronavirus - 19 (COVID-19, COVID, a virus that causes respiratory illness that can spread from person to person) as evidenced by: 1. Failing to ensure that one of the three sampled residents (Residents 1) was wearing a mask while the facility was in an active Covid 19 outbreak (a sudden increase in the number of cases of a disease or medical condition in a specific location or population over a given time period). 2. Failing to ensure that staff were fit tested for N95 respirators/masks (is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) 3. [...]
Inspectors wroteBased on interviews, and record reviews the facility failed to implement abuse policy and procedure when the facility failed to report to the State Agency: 1. The alleged abuse between two residents (Residents 3 and 4). 2. The injury of unknown origin for Resident 5. This deficient practice resulted in Resident 3 and Resident 4 exposed to continuous verbal and mental abuse and for Resident 5 with a potential for contiuned physical abuse. Cross Reference: F726.
Inspectors wroteBased on interviews, and record reviews the facility failed to implement abuse policy and procedure when the facility failed to report to the State Agency: the injury of unknown for 0ne of the three sampled residents (Resident 5). This deficient practice had the potential exposed to continuous verbal and mental abuse from Resident 3 causing mental anguish and emotional distress.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1. That licensed nurses had the specific competencies and skill sets necessary to adequately assess stage Pressure Ulcers (PU-injuries to skin and underlying tissue resulting from prolonged pressure on the skin. They most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips, and tailbone. They range from stage 1 through stage 4: I-intact skin with redness, II-broken skin or intact blister involving top layer of the skin, III- broken skin extending to the fatty tissue, and IV- broken skin extending to the muscle or the bone) for one out of three sampled residents by failing to grade the stage 3 pressure ulcer. 2. To implement abuse policy and procedure when the facility did not Identify and assess all possible incidents of abuse (Resident 5). [...]
Inspectors wroteBased on interviews and record review the facility failed to have a full-time abuse coordinator (Administrator) in the facility. As a result, the incidents of abuse and neglect were not managed and addressed for three of three residents (Residents 3, 4, and 5). Cross Reference:
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of nine sampled residents (Resident 1), who was identified with wandering episodes, was provided supervision, and maintained a safe and hazard free environment as indicated in Resident1 ' s care plan dated 2/21/2024. The facility failed to ensure a full bottle of hand sanitizer was not within Resident 1 ' s access or reach. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records for one of nine sampled residents (Resident 1) in accordance with accepted professional standards and practices by ensuring accurate documentation. This deficient practice had the potential to result in confusion in the care and services rendered to Resident 1 as evident by the inaccurate information entered into Resident 1's clinical record.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement person-centered care plan that included dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning) care needs for one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect the delivery of care and services.
Inspectors wroteBased on interview and record review, the facility failed to sufficiently prepare one of three sampled resident (Resident 1) for a safe and orderly discharge from the facility to the resident ' s home, by failing to include the resident ' s significant other who was the primary care giver in the discharge process and by failing to ensure all necessary medical equipment and supplies were ordered. This failure resulted in resident 1 not having the appropriate Durable Medical Equipment (DME - any medical equipment used in the home to aid in a better quality of living) necessary for safe ambulation and transfer, and with no support/relief for the caregiver (CG). Placing Resident 1 at risk for accidents, injuries, and/ death.
Inspectors wroteBased on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety by not labeling: A.Sliced ham with the use by date. B. Ground chicken with the use by date. C. Chicken meat with the use by date D. Sliced Bacon with the use by date. E. Creamy Italian Dressing with the use by date. F. Sausage with the use by date The facility failed to discard ground beef that was still being stored in the refrigerator after its use by date of 3/21/2024 and failed to maintain the refrigerator and freezer temperature log on 3/30/2024 and 3/31/2024. These deficient practices had the potential to cause food-borne illnesses.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced residents dignity and respect in full recognition of their individualities for two of ten sampled residents (Resident 85 and Resident 92). For Resident 85, the facility failed to cover the urinary collection bag (designed to collect urine drained from the bladder via a catheter) with a privacy bag. For Resident 92, the facility failed to provide dignity by standing over the resident while assisting her during a meal. These deficient practices had the potential to negatively affect the residents psychosocial wellbeing and loss of dignity.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a call light was within reach for one of four sampled residents (Resident 90) investigated for the call lights care area. This deficient practice had the potential to result in the residents not being able to call for facility staff assistance.
Inspectors wroteBased on interview, and record review, the facility failed to ensure the Advance Directive Acknowledgement forms (document provided by the facility that indicates whether a resident has an Advance Directive [AD- a written instruction, recognized under State law, relating to the provision of health care when the individual is unable to make decisions for themselves], would like information regarding creation of an advance directive, or refusal to create an advance directive) were completed thoroughly for two of seven sampled residents (Residents 36 and Resident 85). These deficient practices had the potential for the facility to not honor the residents' medical decisions regarding end-of-life treatment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident was provided a communication device or board with the language that the resident was able to understand for one of one sampled resident (Resident 25). This deficient practice had the potential to delay the delivery of necessary care to the resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADL- refer to an individual's daily self-care activities such as eating, dressing/grooming, bathing/personal hygiene, mobility and toileting) for one of three sampled residents (Resident 29) who had severely impaired vision. This deficient practice had the potential for the resident to experience poor oral intake and be at risk for weight loss.
Inspectors wroteBased on interview and record review, the facility failed to ensure that one of the six sampled staff Certified Nursing Assistant (CNA 2) had a Basic Life Support (BLS - an emergency lifesaving procedure that includes recognition of the signs of sudden cardiac arrest, heart attack, and stroke, as well as the performance of cardiopulmonary resuscitation [CPR] when the heart stops beating) certificate was up to date. This deficient practice had the potential to result in facility residents receiving emergency care that was not up to date, which could lead to resident harm and/or death.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of six sampled residents (Resident 42), who was identified with visual impairment and functional limitation, was provided with activities that stimulate the resident's senses as evidenced by -Failing to provide Resident 42 with a radio and television. -Failing to formulate a care plan for activities for Resident 42. -Failing to perform an activity participation review quarterly for Resident 42. This deficient practice resulted in Resident 42 experiencing emotional distress verbalizing she felt her days were empty; and indicating she was frustrated and uncomfortable because she was bored.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 98) received pressure ulcer (localized skin and soft tissue injuries that form as a result of prolonged pressure and shear, usually exerted over bony prominences) care as indicated in their policy and procedure as evidenced by: -Failing to ensure Resident 98's wound vac (negative pressure wound therapy, a therapeutic technique using a suction pump, tubing, and a dressing to remove excess drainage and promote wound healing) was on and functioning. -Failing to revise Resident 98's Stage 4 pressure ulcer (pressure injuries that extend to muscle, tendon, or bone) care plan. These deficient practices had the potential to cause the development and worsening of Resident 98's pressure ulcer that could lead to severe illness, hospitalization, and death.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled resident's (Resident 84) urinary indwelling urinary catheter (Foley catheter [brand name] a flexible tube (a catheter) inserted into the bladder that remains (dwells) there to provide continuous urinary drainage) was securely anchored (secured to the resident). This deficient practice had the potential for the resident to endure pain from potential pulling tractions and dislodgement of the catheter that may result in urethral (a muscular structure that helps keep urine in the bladder until voiding can occur) trauma.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care and services according to professional standards of practice for one of three sampled residents (Resident 39). The facility implemented the following deficient practices: - the facility administered oxygen via a non-rebreather mask without a physician order and without administering 10 -15 LPM oxygen as required for correct functioning of mask. - failed to monitor oxygen saturation level in accordance with the physician's order - develop/revise a plan of care for Resident 39 who was using oxygen and had had shortness of breath
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 18 sampled residents (Resident 32) who was dependent upon hemodialysis (a medical procedure to remove fluid and waste products from the body) had an emergency kit at resident's bedside. This deficient practice had the potential for resident to receive delay intervention during accidental bleeding.
Inspectors wroteBased on observation, interview, and record review the facility failed to post staffing information per the facility policy and procedure titled, 'Posting Direct Care Daily Staffing Numbers. This deficient practice had the potential for residents, staff, and visitors of the facility to not have knowledge of the facility's staffing information.
Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the nutritional needs for two out of six sampled residents (Resident 14 and Resident 29) by failing to provide double portion meals as ordered by the physician. These deficient practices had the potential to result in decreased nutritional intake and weight loss.
Inspectors wroteBased on observation, interview, and record review, the facility failed to evaluate the food preferences for one of six sampled residents (Resident 1), as evidenced by failing to perform a Nutrition Evaluation for the resident quarterly. This deficient practice had the potential for Resident 1 to feel their needs were not being met and experience emotional distress.
Inspectors wroteBased on interview and record review, the licensed nursing staff failed to maintain accurate medical records in accordance with accepted professional standards for one sampled resident (Resident 16). The facility failed to ensure the licensed nursing staff maintained accurate information regarding the Physician's Order for Life-Sustained Treatment (POLST) for Resident 16. This deficient practice had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment.
Inspectors wroteBased on interview and record review, the facility failed to confirm the identity of two of three sampled residents (Resident 1 and Resident 2). Resident 1 who had an audiology (hearing tests that use different techniques to identify hearing loss) appointment on 2/28/24, the facility failed to use identifiers (information directly associated with an individual that reliably identifies the individual as the person for whom the service or treatment is intended) to confirm the identities of Resident 1 and Resident 2. The facility sent Resident 2 to the audiology examination appointment instead of Resident 1. This deficient practice resulted in Resident 1 missed his appointment, had to be rescheduled and had the potential to delay of treatment.
Inspectors wroteBased on interview and record review the facility failed to notify the responsible party (RP) before changing rooms for one of three sampled residents (Resident 1). This deficient practice had the potential to violate the resident and responsible party's rights in participating in decision making, care planning and treatment choices.
Inspectors wroteBased on interview and record review, the facility failed to implement its' policy and procedures titled, Abuse Investigation and Reporting, for one of three sampled residents, (Resident 1) by failing to report an alleged abuse incident to the State Survey Agency (SSA), the local Ombudsman (examines complaints from people who resides in skilled Nursing Facilities who feel they have been unfairly treated by facility staff) and law enforcement. This deficient practice resulted in a delay of an onsite inspection by the SSA to rule out abuse placing Residents 1 and others residents at risk for further abuse.
20 fire safety citations on file: 8 on May 29, 2026, 7 on April 10, 2025, 5 on April 4, 2024.
| Date | Penalty | Amount or length |
|---|---|---|
| July 15, 2024 | Fine | $144,964 |
| July 15, 2024 | Payment Denial | 7 days from August 24, 2024 |
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) | 4.81 | 4.52 | 3.86 |
| Registered nurses | 0.36 | 0.67 | 0.69 |
| All nursing staff on weekends | 4.00 | 4.09 | 3.42 |
| Nurse aides | 3.30 | ||
| Licensed practical nurses | 1.15 | ||
| Nursing staff turnover (share who left in a year) | 32.7% | 36.7% | 45.8% |
| Registered nurse turnover | 28.6% | 38.1% | 42.9% |
| Administrators who left | 0 |
CMS expects 4.16 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 5.14 on weekdays and 4.00 on weekends, 22% 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 4.61 in April to June 2025 to 4.81 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 | 4.81 | 0.36 | 5.14 | 4.00 | 0.5% | 0 of 90 | 94 |
| Oct to Dec 2025 | 4.91 | 0.32 | 5.27 | 4.01 | 0.3% | 0 of 92 | 94 |
| Jul to Sep 2025 | 4.69 | 0.33 | 5.00 | 3.89 | 0.0% | 0 of 92 | 97 |
| Apr to Jun 2025 | 4.61 | 0.34 | 4.89 | 3.90 | 0.0% | 0 of 91 | 95 |
| 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 | 33.9 | 10.3 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.4 | 0.8 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.2 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 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 | 22.3 | 9.8 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 6.6 | 4.3 | 4.6 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 20.4 | 22.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 1.9 | 11.2 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 3.2 | 2.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.3 | 1.6 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Temple Park Convalescent Hospital's Medicare short-stay residents. On returning residents home or to the community, CMS rates it worse than the national rate (20.4% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
20.4% 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. 48 eligible stays.
12.1% 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. 177 eligible stays.
9.1% 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. 119 eligible stays.
57.4% 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. 122 residents counted.
0.5% 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. 210 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. 210 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. 16 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: TEMPLE PARK CONVALESCENT HOSPITAL INC..
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Kohn, Barry | 5% or greater direct ownership interest | Individual | 100% | 02/26/1976 |
| Kohn, Barry | Corporate director | Individual | 02/26/1976 | |
| Kohn, Toby | Corporate director | Individual | 02/26/1976 | |
| Kohn, Barry | Corporate officer | Individual | 02/26/1976 | |
| Kohn, Toby | Corporate officer | Individual | 02/26/1976 | |
| Cambare, Renfel | Operational/managerial control | Individual | 07/14/2004 | |
| Kohn, Barry | Operational/managerial control | Individual | 02/26/1976 | |
| Kohn, Toby | Operational/managerial control | Individual | 02/26/1976 | |
| Manansala, Harold | Operational/managerial control | Individual | 02/03/2025 | |
| Pardilla, Cecille | Operational/managerial control | Individual | 06/19/2023 | |
| Shtorch, Eyal | Operational/managerial control | Individual | 09/05/2025 | |
| Zamora, Lucia | Operational/managerial control | Individual | 07/31/2023 | |
| Zemel, Elliot | Operational/managerial control | Individual | 11/16/2012 | |
| Cambare, Renfel | Adp of the SNF | Individual | 07/15/2004 | |
| Kohn, Barry | Adp of the SNF | Individual | 02/26/1976 | |
| Kohn, Toby | Adp of the SNF | Individual | 02/26/1976 | |
| Manansala, Harold | Adp of the SNF | Individual | 02/03/2025 | |
| Pardilla, Cecille | Adp of the SNF | Individual | 06/19/2023 | |
| Shtorch, Eyal | Adp of the SNF | Individual | 09/05/2025 | |
| Zamora, Lucia | Adp of the SNF | Individual | 07/31/2023 | |
| Zemel, Elliot | Adp of the SNF | Individual | 11/16/2012 |
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.
These are the official offices in California. NursingHomeClear cannot take or act on complaints.