Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- CaliforniaLowest tier among peers1,154 rated homes · average 3.2★
- Los Angeles CountyLowest tier among peers368 rated homes · average 2.5★
- United StatesLowest tier among peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point1★−1.8 vs CA avg
- StaffingCan add or remove a star3★−0.1 vs CA avg
- Quality measuresCan add or remove a star4★−0.1 vs CA avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersCA avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 27% of peersCA avg3.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above only 24% of peersCA avg4.1★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.99hrsAbove only 23% of peersCA avg4.51Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.38hrsAbove only 29% of peersCA avg0.65Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better44%Above only 29% of peersCA avg38%RN turnover36%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$38,341Above only 21% of peersCA avg$26,970Fines · denials3 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthOct 2021 – Aug 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Aug 21, 2025Cycle 1worst E · no actual harm
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareE · patternCorrected Sep 12, 2025
Jul 10, 2025Cycle 1worst K · immediate jeopardy$13,319
- F908Keep all essential equipment working safely.EnvironmentalD · isolatedCorrected Jul 30, 2025
- F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Quality of Life and CareD · isolatedCorrected Jul 30, 2025
- F732Post nurse staffing information every day.Nursing and Physician ServicesB · patternCorrected Jul 30, 2025
- F810Provide special eating equipment and utensils for residents who need them and appropriate assistance.Nutrition and DietaryD · isolatedCorrected Jul 30, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Jul 25, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jul 30, 2025
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Jul 30, 2025
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Jul 30, 2025
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsD · isolatedCorrected Jul 30, 2025
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningE · patternCorrected Jul 30, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Jul 30, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareK · patternCorrected Jul 24, 2025
Apr 7, 2025Cycle 1worst D · no actual harm
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected May 1, 2025
Mar 19, 2025Cycle 1worst D · no actual harm
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Apr 9, 2025
Feb 5, 2025Cycle 1worst D · no actual harm
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Mar 3, 2025
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Mar 3, 2025
Dec 16, 2024Cycle 2worst D · no actual harm
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Jan 7, 2025
Oct 10, 2024Cycle 2worst D · no actual harm
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 1, 2024
Oct 9, 2024Cycle 2worst D · no actual harm
- F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Pharmacy ServiceD · isolatedCorrected Oct 28, 2024
Jul 19, 2024Cycle 2worst E · no actual harm
- F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Quality of Life and CareE · patternCorrected Aug 12, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Aug 12, 2024
- F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.AdministrationD · isolatedCorrected Aug 8, 2024
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Aug 8, 2024
- F732Post nurse staffing information every day.Nursing and Physician ServicesB · patternCorrected Aug 7, 2024
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsE · patternCorrected Aug 6, 2024
- F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Resident RightsD · isolatedCorrected Aug 7, 2024
- F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and CareE · patternCorrected Aug 5, 2024
- F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and CareD · isolatedCorrected Aug 9, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Aug 8, 2024
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareE · patternCorrected Aug 8, 2024
- F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Quality of Life and CareE · patternCorrected Aug 8, 2024
May 17, 2024Cycle 2worst G · actual harm$16,198
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Jun 14, 2024
- F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Quality of Life and CareG · isolatedCorrected Jun 14, 2024
Mar 8, 2024Cycle 2worst D · no actual harm
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesD · isolatedCorrected Mar 27, 2024
- F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalD · isolatedCorrected Mar 27, 2024
May 23, 2023Cycle 3worst D · no actual harm
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Jun 9, 2023
May 16, 2023Cycle 3worst G · actual harm
- F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 5, 2023
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningG · isolatedCorrected Jun 5, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jun 5, 2023
Apr 19, 2023Cycle 3worst E · no actual harm$8,824
- F886Perform COVID19 testing on residents and staff.Infection ControlD · isolatedCorrected May 30, 2023
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected May 30, 2023
Oct 21, 2021Cycle 3worst E · no actual harm
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Dec 1, 2021
- F685Assist a resident in gaining access to vision and hearing services.Quality of Life and CareD · isolatedCorrected Dec 1, 2021
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Dec 1, 2021
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Dec 1, 2021
- F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Dec 1, 2021
- F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Dec 1, 2021
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Dec 1, 2021
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy ServiceD · isolatedCorrected Dec 1, 2021
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Dec 1, 2021
- F825Provide or get specialized rehabilitative services as required for a resident.Quality of Life and CareD · isolatedCorrected Dec 1, 2021
- F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.AdministrationD · isolatedCorrected Dec 1, 2021
- F881Implement a program that monitors antibiotic use.Infection ControlD · isolatedCorrected Dec 1, 2021
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Dec 1, 2021
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Dec 1, 2021
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Dec 1, 2021
- F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Resident RightsE · patternCorrected Dec 1, 2021
- F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Dec 1, 2021
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Dec 1, 2021
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.99hrs
- Registered nursesRN hours only0.38hrs
- Licensed practical nursesLPN hours1.14hrs
- Nurse aidesCNA hours2.48hrs
- Weekend nursingAll staff on Saturdays and Sundays3.49hrs
- California average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better44%Above only 29% of peersCA avg 38%
- RN turnoverRegistered nurses only36%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy148 certified beds · ~132 residents a day89%Above only 38% of peersCA avg 88%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $38,341In fines
- 3Fines
- 0Payment denials
- $26,970CA avg in fines
Actions on record
- Jul 10, 2025Civil money penalty$13,319
- May 17, 2024Civil money penalty$16,198
- Apr 19, 2023Civil money penalty$8,824
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Corporation
- Chain
- The Ensign Group324 facilities in the chain3.2★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Flagstone Healthcare South LLC
- The Ensign Group INC
- Twomagnets LLC
- John Liu
- Najib Yamak
- Adam Willits
- Soon Burnam
- Alicia Gamero
- Chad Keetch
- Ami Sato
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 055141 · 11900 RAMONA BOULEVARD, EL MONTE, CA, 91732.
- Percentiles compare this facility with every rated nursing home in California and Los Angeles County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









