Map showing the location of PENN MAR HEALTHCARE CENTER in EL MONTE, California
3938 COGSWELL ROAD, EL MONTE, CA, 91732

Overall Score

CMS Five-Star Quality Rating
2/5Below averageCMS Five-Star overall rating

Where it ranks

  • CaliforniaAbove only 16% of peers1,154 rated homes · average 3.2★
  • Los Angeles CountyAbove only 28% of peers368 rated homes · average 2.5★
  • United StatesAbove only 20% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point2★−0.8 vs CA avg
  • StaffingCan add or remove a star1★−2.1 vs CA avg
  • Quality measuresCan add or remove a star5★+0.9 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.

  • Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersCA avg2.8★U.S. avg2.8★
What is health inspection rating?

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.

Why it matters

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 turnover1★Lowest tier among peersCA avg3.1★U.S. avg2.9★
What is staffing rating?

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.

Why it matters

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 assessments5★Above 57% of peersCA avg4.1★U.S. avg3.6★
What is quality measures rating?

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.

Why it matters

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 staff3.16hrsAbove only 2% of peersCA avg4.51Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

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 only0.11hrsLowest tier among peersCA avg0.65Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

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 better55%Above only 10% of peersCA avg38%RN turnover100%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

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$4,893Above only 42% of peersCA avg$26,970Fines · denials1 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
74citations
22inspection dates
1actual harm (G–I)
0immediate jeopardy (J–L)
Dec 4, 2025most recent

Citations by monthMar 2023 – Dec 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Dec 4, 20251 citationCycle 1worst D · no actual harm
  1. 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 26, 2025
Nov 21, 202514 citationsCycle 1worst F · no actual harm
  1. F911Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.EnvironmentalB · patternCorrected Dec 15, 2025
  2. 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 15, 2025
  3. F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 15, 2025
  4. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Dec 15, 2025
  5. 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 Dec 15, 2025
  6. F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesE · patternCorrected Dec 15, 2025
  7. F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Nursing and Physician ServicesF · widespreadCorrected Dec 15, 2025
  8. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Dec 15, 2025
  9. 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 15, 2025
  10. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Dec 15, 2025
  11. F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyAdministrationE · patternCorrected Dec 15, 2025
  12. F881Implement a program that monitors antibiotic use.Infection ControlB · patternCorrected Dec 15, 2025
  13. F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Infection ControlB · patternCorrected Dec 15, 2025
  14. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsE · patternCorrected Dec 15, 2025
Jul 9, 20251 citationCycle 1worst D · no actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 4, 2025
May 14, 20253 citationsCycle 1worst E · no actual harm
  1. F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesE · patternCorrected Jun 6, 2025
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jun 6, 2025
  3. F732Post nurse staffing information every day.Nursing and Physician ServicesB · patternCorrected Jun 6, 2025
May 7, 20251 citationCycle 1worst D · no actual harm
  1. 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 Jun 6, 2025
Apr 15, 20251 citationCycle 1worst D · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected May 21, 2025
Mar 28, 20251 citationCycle 1worst D · no actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 21, 2025
Jan 16, 20252 citationsCycle 2worst E · no actual harm
  1. F839Employ staff that are licensed, certified, or registered in accordance with state laws.AdministrationE · patternCorrected Feb 12, 2025
  2. F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesE · patternCorrected Feb 12, 2025
Dec 20, 20243 citationsCycle 2worst D · no actual harm
  1. 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 Jan 14, 2025
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jan 14, 2025
  3. 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 Jan 14, 2025
Dec 6, 202412 citationsCycle 2worst E · no actual harm
  1. 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 30, 2024
  2. Assure that each resident’s assessment is updated at least once every 3 months.Resident Assessment and Care PlanningE · patternCorrected Dec 30, 2024
  3. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Dec 30, 2024
  4. 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 30, 2024
  5. F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Nursing and Physician ServicesE · patternCorrected Dec 30, 2024
  6. F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesD · isolatedCorrected Dec 30, 2024
  7. F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Nursing and Physician ServicesE · patternCorrected Dec 30, 2024
  8. F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesE · patternCorrected Dec 30, 2024
  9. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Dec 30, 2024
  10. 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 Dec 30, 2024
  11. 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 30, 2024
  12. F911Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.EnvironmentalB · patternCorrected Dec 30, 2024
Oct 23, 20241 citationCycle 2worst E · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Nov 16, 2024
Aug 28, 20241 citationCycle 2worst E · no actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Sep 22, 2024
Aug 5, 20241 citationCycle 2worst E · no actual harm
  1. F865Have a plan that describes the process for conducting QAPI and QAA activities.AdministrationE · patternCorrected Aug 29, 2024
Jul 12, 20241 citationCycle 2worst D · no actual harm
  1. 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 Aug 2, 2024
Jun 4, 20244 citationsCycle 2worst G · actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Jun 28, 2024
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected Jun 28, 2024
  3. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Jun 28, 2024
  4. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 28, 2024
May 7, 20241 citationCycle 2worst E · no actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected May 30, 2024
Apr 2, 20242 citationsCycle 2worst D · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Apr 25, 2024
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Apr 25, 2024
Mar 20, 20243 citationsCycle 2worst E · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Apr 16, 2024
  2. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 16, 2024
  3. 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 PlanningE · patternCorrected Apr 16, 2024
Dec 8, 202314 citationsCycle 3worst E · no actual harm
  1. F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalE · patternCorrected Jan 8, 2024
  2. F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalD · isolatedCorrected Jan 8, 2024
  3. F732Post nurse staffing information every day.Nursing and Physician ServicesD · isolatedCorrected Jan 8, 2024
  4. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Jan 8, 2024
  5. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Jan 8, 2024
  6. F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and DietaryE · patternCorrected Jan 8, 2024
  7. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Jan 8, 2024
  8. F911Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.EnvironmentalB · patternCorrected Jan 8, 2024
  9. F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsD · isolatedCorrected Jan 8, 2024
  10. 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 RightsB · patternCorrected Jan 8, 2024
  11. 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 Jan 8, 2024
  12. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Jan 8, 2024
  13. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jan 8, 2024
  14. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Jan 8, 2024
Nov 7, 20232 citationsCycle 3worst E · no actual harm
  1. 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 ServicesE · patternCorrected Dec 7, 2023
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Dec 7, 2023
Jul 28, 20232 citationsCycle 3worst D · no actual harm
  1. F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesD · isolatedCorrected Aug 25, 2023
  2. 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 Aug 25, 2023
Mar 16, 20233 citationsCycle 3worst D · no actual harm
  1. 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 21, 2023
  2. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 21, 2023
  3. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 21, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.16hrsAbove only 2% of peers−1.35 vs CA avg
  • Registered nursesRN hours only0.11hrsLowest tier among peers−0.54 vs CA avg
  • Licensed practical nursesLPN hours1.16hrs
  • Nurse aidesCNA hours1.89hrs
  • Weekend nursingAll staff on Saturdays and Sundays2.69hrs
  • California average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better55%Above only 10% of peersCA avg 38%
  • RN turnoverRegistered nurses only100%Not ranked by CMS
  • Administrators who leftIn the past year1Leadership changed
  • Occupancy45 certified beds · ~45 residents a day100%Top 2%CA avg 88%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $4,893In fines
  • 1Fine
  • 0Payment denials
  • $26,970CA avg in fines
Above only 42% of peersFewer fines than 42% of rated homes in California

Actions on record

  1. Jan 8, 2024Civil money penalty$4,893

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Independent
Certification
Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Ownership Data Not Available

    Person Organization

    Sources & notes

    Public data, updated quarterly

    Data 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 05A360 · 3938 COGSWELL ROAD, 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.

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