Home / California / Fullerton
201 East Bastanchury, Fullerton, CA 92835 · Orange County · (714) 870-0060
59 certified beds, about 51 residents a day · For profit - Corporation · Medicare and Medicaid since 1996
CMS Care Compare ratings, data as of September 1, 2026 · CCN 555671 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on February 23, 2026, inspectors cited 21 health deficiencies (the California average is 15.6, the national average 9.2).
None of its 58 health citations since March 2024 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 4.86 hours per resident per day, against 4.52 across California and 3.86 nationally. Registered nurses accounted for 0.77 of those hours.
24.3% of nursing staff left within the year CMS measured (California average 36.7%).
CMS links it to Nahs, an affiliated group of 12 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 58 health citations on file.
Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure proper medication storage for one of one medication carts (Medication Cart A) and one of two medication rooms (Medication Room A). * The facility failed to ensure inhalation solution vials were stored in the foil pouch, and labeled with opened date in Medication Cart A. * The facility failed to ensure an oral alendronate (bisphosphonates, prevent bone breakdown and increase bone density) medication was not stored with cyclosporine ophthalmic emulsion (immunomodulators, works by decreasing swelling in the eye to allow for tear production) eyedrops and glucometer control solutions in Medication Cart A. [...]
Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the appropriate infection control practices were implemented as evidenced by: * The facility failed to ensure a visitor for Resident 61 who was on C-Diff isolation was educated on isolation precautions like handwashing instead of using ABHR and wearing gloves. * The facility failed to ensure the housekeeper wore a protective gown when sorting soiled linens. * The facility failed to ensure the employee's personal belongings were not stored with the clean blankets and tablecloths used by the residents in the clean linen area. * The facility failed to ensure Resident 43's urinal filled with urine was not placed near the resident's cupcake. These failures had the potential for spreading infection.
Inspectors wroteBased on observation, interview, medical record review, facility document review and facility P&P review, the facility failed to ensure the residents' bed inspection and entrapment assessments were conducted and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of side rails for three of four final sampled residents (Residents 4, 21, and 43) and one non-sampled resident (Resident 61) reviewed for the use of side rails. * The facility failed to ensure a bed inspection was completed for Resident 21 who was on bariatric bed. * The facility failed to ensure an entrapment assessment was accurately conducted for Resident 4 who had bilateral 1/2 side rails. * The facility failed to ensure an entrapment assessment was accurately conducted for Resident 43 who had bilateral 1/2 side rails. [...]
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled resident (Resident 43) reviewed for the side rail use remained free from the accident hazards associated with the use of the elevated side rails. * The facility failed to obtain informed consent for the use of the bilateral upper side rails for Resident 43. This failure had the potential for the resident to be unaware of the risks associated with the use of the bilateral upper side rails and risk for serious injury to the resident.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to determine whether it was safe for one of 12 final sampled residents (Resident 21) to self-administer the medications left at bedside. * Resident 21 was observed with multiple medications at bedside. However, Resident 21 was assessed to be mentally and physically incapable of self-administering medications. In addition, there were no physician's orders to self-administer and to administer the medications found at bedside. These failures had the potential for Resident 21 to administer the medications inaccurately and could affect his well-being.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the personal property was protected from loss or theft for one of three final sampled residents (Resident 14) reviewed for personal property. * The facility failed to ensure Resident 14's CPAP machine was listed in the resident's inventory list. This failure had the potential for the resident's property to get lost or stolen.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled resident (Resident 7) reviewed for unnecessary medications were free from unnecessary psychotropic medications. * The facility failed to implement Resident 7's non-pharmacological interventions for the use of mirtazapine and trazodone (antidepressant) medications. This failure had the potential for adverse effects from the psychotropic medications and to negatively impact the residents' well-being.
Inspectors wroteBased on interview and medical record review, the facility failed to ensure the PASRR was complete for one of 12 final sampled residents (Resident 5). * Resident 5 did not receive a Level II mental health evaluation, after a Level 1 Screening was positive for serious mental illness reviewed for PASRR. This failure posed the risk for Resident 5 not receiving specialized services beneficial to the resident's wellbeing.
Inspectors wroteBased on observation, interview, and medical record review, the facility failed to develop the comprehensive plan of care to reflect the individual care needs for two of 12 final sampled residents (Residents 21 and 57). * The facility failed to develop a care plan problem to address Resident 21's behavior of ordering and keeping medications at bedside. * The facility failed to develop a care plan problem to address Resident 57's Permacath related to dialysis use. These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents.
Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one non-sampled resident (Resident 61) reviewed for pressure injury was provided the necessary care and services. The facility failed to ensure Resident 61's LAL mattress setting was accurate to the resident's weight and comfort. This failure had the potential for the resident not to receive the appropriate care and services to promote skin healing.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 7) was free from accident hazards. * The facility failed to implement bilateral floor mattress as ordered by the physician as a fall risk precaution for Resident 7. This failure had the potential for serious injury to the resident.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 9) received care and services to maintain acceptable nutritional status. * The facility failed to ensure the RD's recommendations for Cholecalciferol 2,000 IU oral daily, Vitamin C 500 mg oral daily for 30 days and Prostat SF (liquid protein supplement) 30 ml oral daily was implemented. This failure had the potential to compromise Resident 9's nutritional status.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous access for one of 12 final sampled residents (Resident 37). * The facility failed to ensure the PICC line external catheter and arm circumference measurements were completed and documented upon admission in the medical records for Resident 37. This failure had the potential to delay the identification of catheter related complications for the resident.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for one of 12 final sampled residents (Resident 43) reviewed for oxygen therapy. * The facility failed to ensure Resident 43's oxygen tubing was labeled and dated. This failure had the potential to place the resident at risk of receiving improper respiratory care.
Inspectors wroteBased on observations, interview, medical record review, and facility P&P review, the facility failed to provide adequate pain management for two of two final sampled residents (Residents 21 and 56) reviewed for pain management. * The facility failed to ensure Resident 21 was administered oxycodone (narcotic analgesic) medication as per the physician's order. In addition, the facility failed to monitor Resident 21's sedation level, BP, and apical pulse per the physician's order related to the administration of oxycodone medication. * Resident 56's ordered pain scale did not match the facility's standardized pain scale. In addition, the resident was administered PRN pain medication for a pain level of 5, which was below the ordered pain level of 6-10. These failures had the potential for Residents 21 and 56 to not receive effective treatment for pain.1. [...]
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate dialysis care was provided for one of two final sampled residents (Resident 9) reviewed for dialysis services. * The facility failed to ensure the emergency dialysis kit kept at bedside was complete and contained a scissor clamp for Resident 9. This failure posed the risk of possible medical complications for Resident 9.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled resident (Resident 43) reviewed for the side rail use remained free from the accident hazards associated with the use of the elevated side rails. * The facility failed to ensure the physician's order was obtained for the use of bilateral half side rails for Resident 43. * The facility failed to ensure a care plan was developed to address the use of bilateral half side rails for Resident 43. * The facility failed to ensure the side rail assessment and the least restrictive interventions were completed prior to the use of bilateral half side rails for Resident 43. These failures had the potential risk for serious injury to the resident.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's recommendations from drug regimen review in January 2026 were acted upon for one of five final sampled residents (Resident 7) reviewed for pharmacy services. * The facility failed to ensure the drug regimen review recommendations of trying and documenting non-pharmacological interventions for January 2026 were acted upon for Resident 7. This failure placed the resident at risk for receiving unnecessary medications, increasing their risk for side effects.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to maintain an accurate medical record for one of 12 final sampled residents (Resident 56). * The facility failed to ensure the Resident 56's pain level monitoring for each shift was accurately documented. This failure resulted in inaccurate medical records.
Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to monitor and address the use of the antibiotics for one final sampled resident (Resident 51) and one non-sampled resident (Resident 40) reviewed for antibiotic stewardship. * The facility failed to ensure the McGeer's criteria assessment was completed in a timely manner for Residents 40 and 51 when the residents were started with antibiotics. This failure had the potential for the antibiotics to be used when they were not indicated and the development of antibiotic-resistant bacteria.
Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the glucometer in Medication Cart A, and the refrigerators used to store medications in Medication Rooms A and B were maintained in a safe operating condition. * The facility failed to ensure the glucometer calibration was conducted for the glucometer in Medication Cart A. Furthermore, the facility failed to ensure the glucose strips and control solutions had an expiration date of 90 days after opening, as per the manufacturer's information. * The facility failed to ensure the freezer compartment inside the refrigerator used for medications in Medication Room A was free of ice buildup. This had the potential to affect the refrigerator's functionality and the potentially affect the potency of the medications stored inside the refrigerator. [...]
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) reviewed for falls was accurately assessed for the risk for falls. * Residents 1's Fall Risk assessment dated [DATE], showed multiple inaccurate entries, which resulted for the resident to have a lower score for a fall risk. This failure had the potential for the resident to experience adverse events related to falls.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident's medical record was complete and accurate for one of three sampled residents (Resident 1). * Resident 1's 72 Hour Neuro Check - List had incorrect time intervals between the one hour and two hour neuro check section, which resulted in all subsequent time entries to be delayed by one hour. This failure posed the risk for the resident's care needs not being met as his medical record information was inaccurate.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 1) was free from the physical restraints. * CNA 1 wrapped a bed sheet around Resident 1's waist and tied it behind the resident's wheelchair, preventing Resident 1 from easily removing the material. This failure posed the risk of restricting the resident's freedom of movement and further compromising the resident's independence and psychosocial well-being.
Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to thoroughly investigate an allegation of abuse for one of four sampled residents (Resident 1). * The facility failed to interview Resident 1 (alleged victim) and CNA 1 (alleged perpetrator) when Resident Representative 1 reported Resident 1 was tied to his wheelchair with a bedsheet, and when Resident 1 alleged CNA 1 hit him in the face and kicked him in the stomach. This failure had the potential to put the resident at risk for further abuse.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the treatment and care in accordance with the professional standards of practice for one of four sampled residents (Resident 1). * The facility failed to ensure the physician was notified in a timely manner when Resident Representative 1 reported Resident 1 was tied to his wheelchair with a bedsheet, and when Resident 1 alleged CNA 1 hit him in the face and kicked him in the stomach * The facility failed to ensure the physician and resident representative were notified when Resident 1 was found on the floor and was observed with purplish discoloration on his left thigh. In addition, the facility failed to ensure monitoring of the neurological status was conducted when the resident had unwitnessed fall. [...]
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the quality care and services were provided for one of 14 final sampled residents (Resident 8) and two nonsampled residents (Residents 26 and 293). * The facility failed to ensure the physician's order was obtained, the assessment was completed, and the appropriate instructions were obtained to maintain the appropriate care of the resident's blood glucose monitoring device for Resident 26. * The facility failed to ensure the transfer orders and instructions from the acute care hospital were followed through and communicated to the resident's attending physician for Resident 293. * The facility failed to assess Resident 8 and notify the physician timely when Resident 8's oxygen saturation levels were 91 to 92% as per the physician's order to keep the oxygen saturation above 92%. [...]
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for one of 14 final sampled residents (Resident 33), and two nonsampled residents (Residents 292 and 293). * The facility failed to ensure the PICC line external catheter baseline measurements were obtained and documented for Resident 292. * The facility failed to ensure the PICC line external catheter baseline measurements were obtained and documented for Resident 293. * The facility failed to ensure Resident 33's PIV site was labeled with the date, time, and licensed nurse's initials. These failures had the potential to delay the identification of intravenous catheter related complications for the residents.
Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the safe respiratory care services for two of four final sampled residents (Residents 8 and 294) reviewed for the respiratory care. * The facility failed to ensure Resident 8's non-invasive ventilator machine was cleaned as per the manufacturer's guidelines and the headgear and tubing were cleaned as per the facility's P&P. * The facility failed to ensure Resident 294's CPAP machine was cleaned as per the manufacturer's guidelines and failed to ensure the mask with straps and tubing were placed in the clear plastic bag when not in used. These failures had the risk for equipment contamination and respiratory complications, which might adversely affect the health and well-being of Residents 8 and 294.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration of the medications as evidenced by: * LVN 2 failed to administer Resident 542's dexamethasone (steroid, anti-inflammation medication) as per the physician's order. This failure had the potential to negatively affect Resident 542's health condition, for possible complications.
Inspectors wroteBased on interview, medical record review, and facility review, the facility failed to ensure three of five final sampled residents (Residents 27, 33, and 36) reviewed for the unnecessary medications were free from the unnecessary psychotropic drugs. * The facility failed to ensure Resident 33's orthostatic blood pressure was monitored as ordered by the physician related to the use of the sertraline (antidepressant) medication. * The facility failed to ensure Resident 36's orthostatic blood pressures were accurately monitored for the use of the Seroquel (antipsychotic medication), bupropion (antidepressant medication), and desvenlafaxine (antidepressant medication); the facility failed to document the implementation of the non-pharmacological interventions for Resident 36's use of the Seroquel, bupropion, desvenlafaxine, and Depakote(mood stabilizer) medications. [...]
Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * Seven cups of apple juice and one cup of yogurt were unlabeled and undated inside the walk-in refrigerator. This failure had the potential to result in foodborne illnesses for the residents receiving food prepared in the kitchen.
Inspectors wroteBased on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment; 2. Resources necessary to care for residents including weekends; 3. A plan to maximize recruitment and retention of direct care staff; and 4. A contingency plan for staffing needs. This failure had the potential to not meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.
Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to perform the hand hygiene and maintain the infection practices to help prevent the development and transmission of diseases and infection. * The Activity Assistant failed to performed hand hygiene after removing the PPE when coming out of Room A with Novel Respiratory Precaution sign. * CNA 7 failed to perform hand hygiene after removing the PPE and leaving Room A. * CNA 1 failed to performed hand hygiene after removing the PPE from answering the call light in Room A. * The facility failed to ensure CNA 8 followed the enhanced barrier precautions for Resident 292 when changing the resident's disposable briefs. These findings failed to prevent the development and transmission of communicable diseases and infections.
Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDS was coded accurately for one of 14 final sampled residents (Resident 33). This failure had the potential for the resident to not receive individualized plans of care to address the resident's individual care needs.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the pneumococcal immunization was offered and administered to one nonsampled residents (Resident 15) reviewed for pneumococcal immunization. This failure placed the residents at risk to acquire pneumococcal infection (also known as pneumococcal disease, is caused by the bacteria Streptococcus pneumoniae, or pneumococcus).
Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to protect the resident's rights from the verbal and physical abuses by another resident for two of six sampled residents (Residents 2 and 3). * Resident 1 was being assisted by two nursing aide students when Resident 1 angrily yelled and demanded Resident 2 to leave Room A. Resident 1 hit Resident 2's right foot as witnessed by the two nursing aide students on 11/16/24. Resident 2 was assessed with no physical injuries, monitored for emotional distress, and transferred to Room B. * CNA 3 witnessed Resident 1 yelling and cursing at Resident 3 on 12/13/24. Resident 3 stated Resident 1 also raised his walker as if going to hit him. Resident 3 stated he felt scared to go back to Room A. Resident 3 was then transferred to Room C. [...]
Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility did not report the allegation of abuse timely as per the facility's P&P for two of six sampled residents (Resident 2 and 3) * Resident 1 was being assisted by two nurse aide students when Resident 1 angrily yelled and demanded Resident 2 to leave Room A. Resident 1 hit Resident 2's right foot as witnessed by the two nurse aide students, on 11/16/24. Resident 2 was assessed with no physical injuries, monitored for emotional distress, and was then transferred to Room B. The initial SOC-341 filed to CDPH on 11/16/24, was incomplete and did not show the description of the incident. [...]
Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to investigate an allegation of abuse as per the facility's P&P and monitor the residents after the alleged abuse for three of three sampled residents (Residents 1, 2, and 3). * Resident 1 was being assisted by two nurse aide students, when Resident 1 angrily yelled and demanded Resident 2 to leave Room A. Resident 1 hit Resident 2's right foot, as witnessed by the two nurse aide students, on 11/16/24. Resident 2 was assessed with no physical injuries, monitored for emotional distress, and was then transferred to Room B. The facility failed to interview staff members on all shifts who had a contact with the resident during the period of the alleged incident asper the facility's P&P. [...]
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented. * The facility failed to include the residents who exhibited sign and symptoms of infection who were not prescribed antibiotics on the Surveillance program from January 2023 to February 2024. * CNA 3 failed to perform hand hygiene after touching Resident 35's shoulder and prior to serving a meal tray to Resident 50. * The facility failed to clean and disinfect the blood pressure machine between Resident 24 and Resident 404's use. * The facility failed to disinfect the blood glucose monitoring device after being used and the LVN did not change gloves prior to insulin administration for Resident 37. [...]
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to implement their antibiotic stewardship program when the facility failed to conduct an assessment for the McGeer's criteria to determine the true infection. This failure had the potential for inaccurately identifying for true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antibiotics.
Inspectors wroteBased on observation, interview, and facility document review, the facility failed to maintain the essential equipment in a safe operating condition. * The facility failed to ensure the ice machine located in the dining room was cleaned and sanitized as per the manufacturer's instruction manual. This failure had the potential for the ice machine not being maintained in a safe operating condition and posed the risk of equipment to function improperly.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 22 final sampled residents (Resident 505) was assessed to safely self-administer the medications prior to performing the self-administration of medications. This failure had the potential to negatively impact the resident's physiological well-being and could administer the medications inaccurately.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the physician was notified of the changes in conditions for one of 22 final sampled residents (Resident 305) as evidenced by: * The facility failed to notify the physician for Resident 305's multiple scattered reddish, maroon colored skin discoloration to the bilateral upper extremities. This failure had the potential for Resident 305 not to receive the appropriate treatment to address his medical needs and to have a delay in care and treatments.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the privacy was provided for one of 22 final sampled residents (Resident 18) and three nonsampled residents (Residents 14, 24, and 32). * The privacy curtain was not pulled while providing the ADL care to Residents 14, 18, and 32. * The facility failed to ensure the privacy was provided during the GT medication administration for Resident 24. These failures had the potential to negatively affect the dignity of the residents and violate the residents' right to privacy.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide a summary of the baseline care plan for two of 22 final sampled residents (Residents 304 and 307). This failure had the potential for inappropriate interventions and care for these residents.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop and implement the comprehensive plans of care to reflect the individual care needs of three of 22 final sampled residents (Residents 12, 304, and 505). * The facility failed to develop a care plan with goal and interventions to address Resident 12's RNA services. * The facility failed to implement a care plan intervention to place TED hose (Thrombo-Embolic Deterrent, specially designed knee-high, thigh-high or waist high stockings that help prevent blood clots and swelling in your legs) to swollen extremities for Resident 304. * The facility failed to implement a pad alarm in bed/wheelchair for Resident 505. These failures posed the risk of not providing appropriate, consistent, and individualized care to these residents.
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plans of care for one of 22 final sampled residents (Resident 12) was revised to reflect the resident's current care needs and interventions. * The facility failed to ensure Resident 12's plan of care was revised to reflect Resident 12 was discharged from therapy services. This failure posed the risk of not providing Resident 12 with individualized and person-centered care.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure a non-English speaking resident's communication needs were met for one nonsampled resident (Resident 31) and failed to ensure the translation service contact information was available for staff. These failures had the potential for a delay in the facility's ability to communicate with the resident.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to attain or maintain the highest practicable well-being for one of 22 final sampled residents (Resident 305). * The facility failed to identify and assess for Resident 305's multiple scattered reddish, maroon-colored skin discoloration to his bilateral upper extremities. This failure had the potential risk of not providing appropriate care for Resident 305.
Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of 22 final sampled residents (Resident 505) remained free from the accident hazards. * The facility failed to monitor Resident 505 for 72 hours after her fall according to the facility's P&P. This failure had the potential to place the resident at risk for serious injury.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary GT care for one nonsampled resident (Resident 24). * The facility failed to ensure the gastric residual volume (volume of fluid remaining in the stomach) was checked before flushing and administering a bolus feeding (a single dose of medication or other substance given over a short period of time) to Resident 24. This failure posed the potential risk for Resident 24 to have aspiration during the medication administration and for developing complications related to GT.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services for three of 22 final sampled residents (Residents 9, 13, and 50) and one nonsampled resident (Resident 51) to meet the needs of each resident as evidenced by: * The facility failed to ensure the controlled drug Percocet (opioid analgesic) 5 mg-325 mg tablet signed out from the controlled drug record was documented as administered on the MAR for Resident 9; and the controlled drug, Norco (opioid analgesic) 5 mg-325 mg tablet signed out from the controlled drug record was documented as administered on the MAR for Resident 50. * The facility failed to the removed and not used controlled drug tablet was properly discard and not placed back into the bubble pack and taped for Resident 51. [...]
Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 22 final sampled residents (Resident 2) was provided the management for the use of psychotropic medications (medications that affect the mind, emotions, and behavior). * The facility failed to ensure the non-pharmacological approaches were provided to Resident 2 while receiving alprazolam (to treat anxiety disorders and panic disorders-sudden, unexpected attacks of extreme fear and worry about these attacks), bupropion (to treat depression), citalopram (to treat depression), and Quetiapine (Seroquel, medicine used to treat several kinds of mental health conditions including schizophrenia and bipolar disorder. It helped regulate the mood, behaviors, and thoughts) medications. This failure had the potential to cause harm to Resident 2.
Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication rate was 10.34%. One of two licensed nurses (LVN 2) observed administering the medications was found to have errors while administering the medications to two nonsampled residents (Residents 24 and 404). * The facility failed to ensure Resident 24 received the prescribed nasal gel and correct amount of the diclofenac sodium topical gel (to relieve pain from arthritis in certain joints such as those of the knees, ankles, feet, elbows, and hands). * LVN 2 prepared the expired vitamin D3 for Resident 404 during the medication pass observation. These failures had the potential for the residents to receive ineffective therapeutic effects of the medications and had negatively affect the residents' health.
Inspectors wroteBased on observation, interview, facility record review, and facility P&P review, the facility failed to ensure the medications were properly stored and labeled for two of 22 sampled residents (Residents 307 and 505) and one nonsampled resident (Resident 37); and failed to ensure the medication room refrigerator temperatures were monitored in accordance with the facility's P&P. * The facility failed to dispose the insulin pen beyond the used by date for Resident 37. * The facility failed to dispose the medication and medical supplies after the expiration date. * The facility failed to dispose the opened sterile packages of Collagen dressing and disposable urinary drainage bag. * The facility failed to appropriately label the Apokyn Pen, blood glucose strips, and Miralax bottle with an open date. * The facility failed to monitor the temperatures of the medication room refrigerator. [...]
Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical record for one of 22 final sampled residents (Resident 13) was complete and accurate. This failure had the potential for the resident's accurate clinical status not being available and communicated to care team.
Inspectors wroteBased on interview and observation, the facility failed to ensure the call light in the resident's room was functioning for one of 22 final sampled residents (Resident 204). This failure had the potential for a delay in assisting the resident.
4 fire safety citations on file: 2 on February 23, 2026, 2 on March 22, 2024.
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | California | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.86 | 4.52 | 3.86 |
| Registered nurses | 0.77 | 0.67 | 0.69 |
| All nursing staff on weekends | 4.33 | 4.09 | 3.42 |
| Nurse aides | 2.60 | ||
| Licensed practical nurses | 1.49 | ||
| Nursing staff turnover (share who left in a year) | 24.3% | 36.7% | 45.8% |
| Registered nurse turnover | 37.5% | 38.1% | 42.9% |
| Administrators who left | 0 |
CMS expects 4.48 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 5.08 on weekdays and 4.33 on weekends, 15% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.67 in April to June 2025 to 4.86 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 | 4.86 | 0.77 | 5.08 | 4.33 | 0.0% | 0 of 90 | 51 |
| Oct to Dec 2025 | 4.88 | 0.71 | 5.13 | 4.25 | 0.0% | 0 of 92 | 52 |
| Jul to Sep 2025 | 4.70 | 0.66 | 4.88 | 4.25 | 0.0% | 0 of 92 | 52 |
| Apr to Jun 2025 | 4.67 | 0.66 | 4.83 | 4.28 | 0.0% | 0 of 91 | 52 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| California, Jan to Mar 2026 | 4.36 | 0.59 | 4.52 | 3.97 | 2.3% | 0.5% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| California, all employers | |||
| CNAs (nursing assistants) | $22.90 | $22.04 to $26.35 | 110,060 |
| LPNs and LVNs | $38.34 | $35.98 to $45.06 | 82,850 |
| Registered nurses | $67.44 | $58.87 to $83.25 | 338,940 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | California | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 9.2 | 10.3 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.8 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.5 | 1.2 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.1 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 7.1 | 9.8 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 2.4 | 4.3 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 1.6 | 12.0 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 19.3 | 22.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 9.7 | 11.2 | 12.0 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Terrace View Care Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (70.5% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
70.5% this home
Better than the national rate
US median of homes 51.5% · California: 301 better, 190 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 431 eligible stays.
9.0% 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. 423 eligible stays.
6.7% 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. 242 eligible stays.
79.5% 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. 176 residents counted.
0.0% this home
Median of homes: California0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 262 residents counted.
0.2% 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. 262 residents counted.
99.5% 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. 186 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: SUN HAVEN CARE, INC.. CMS links this home to Nahs, a group of 12 nursing homes averaging 4 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Nahs Holding Inc | 5% or greater indirect ownership interest | Organization | 100% | 06/30/2018 |
| Dahl, Brenden | W-2 managing employee | Individual | 03/21/2018 | |
| Dahl, Brenden | Corporate director | Individual | 03/21/2018 | |
| Ellis-Sherinian, James | Corporate director | Individual | 10/01/2021 | |
| Jergensen, Jeremy | Corporate director | Individual | 03/21/2018 | |
| Dahl, Brenden | Corporate officer | Individual | 03/21/2018 | |
| Daly, Jeffrey | Corporate officer | Individual | 03/21/2018 | |
| Lundquist, Victor | Corporate officer | Individual | 03/21/2018 | |
| Dahl, Brenden | Operational/managerial control | Individual | 03/21/2018 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
Licensed assisted living homes in the same town or within 5 miles, each with its California inspection record.
These are the official offices in California. NursingHomeClear cannot take or act on complaints.