Map showing the location of MACLAY HEALTHCARE CENTER in SYLMAR, California
12831 MACLAY STREET, SYLMAR, CA, 91342

Overall Score

CMS Five-Star Quality Rating
2/5Below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

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 point1★−1.8 vs CA avg
  • StaffingCan add or remove a star3★−0.1 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.

  • Special Focus Facility candidateThis facility is on the CMS candidate list for the Special Focus Facility program, meaning it is among the poorest-performing facilities in its state on recent inspections.
  • 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 cycles1★Lowest tier among 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 turnover3★Above only 27% of 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 staff4.24hrsAbove 51% 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 only0.36hrsAbove only 25% of 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 better47%Above only 21% of peersCA avg38%RN turnover60%
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$297,315Above only 1% of peersCA avg$26,970Fines · denials5 · 4
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
175citations
44inspection dates
6actual harm (G–I)
6immediate jeopardy (J–L)
Sep 15, 2025most recent

Citations by monthOct 2022 – Sep 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.

Sep 15, 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 Oct 15, 2025
Aug 28, 20252 citationsCycle 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 Sep 19, 2025
  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 Sep 19, 2025
Jul 9, 20251 citationCycle 1worst D · no actual harm
  1. 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 12, 2025
Jun 3, 20254 citationsCycle 1worst 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 Jun 27, 2025
  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 Jun 27, 2025
  3. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Jun 27, 2025
  4. F825Provide or get specialized rehabilitative services as required for a resident.Quality of Life and CareD · isolatedCorrected Jun 27, 2025
Apr 28, 20251 citationCycle 1worst E · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected May 9, 2025
Mar 22, 20257 citationsCycle 1worst J · immediate jeopardy$51,704, payment denial
  1. F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningD · isolatedCorrected Apr 18, 2025
  2. F583Keep residents' personal and medical records private and confidential.Resident RightsE · patternCorrected Apr 18, 2025
  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 ExploitationJ · isolatedCorrected Apr 18, 2025
  4. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 18, 2025
  5. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Apr 18, 2025
  6. F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Nursing and Physician ServicesE · patternCorrected Apr 18, 2025
  7. 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 Apr 18, 2025
Jan 28, 20252 citationsCycle 2worst D · no actual harm
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Feb 12, 2025
  2. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Feb 12, 2025
Jan 16, 20251 citationCycle 2worst D · no actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Feb 4, 2025
Dec 24, 20245 citationsCycle 2worst D · no actual harm
  1. F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningD · isolatedCorrected Jan 9, 2025
  2. 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 9, 2025
  3. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jan 9, 2025
  4. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Jan 9, 2025
  5. F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Jan 9, 2025
Dec 18, 20241 citationCycle 2worst 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 Dec 30, 2024
Oct 31, 20242 citationsCycle 2worst D · no actual harm$17,660, $112,506, payment denial
  1. 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 11, 2024
  2. 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 Nov 11, 2024
Oct 24, 20242 citationsCycle 2worst G · actual harm$17,660, $112,506, payment denial
  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 ExploitationG · isolatedCorrected Nov 8, 2024
  2. 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 RightsE · patternCorrected Nov 8, 2024
Oct 11, 202430 citationsCycle 1worst J · immediate jeopardy$17,660, $112,506, payment denial
  1. F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalE · patternCorrected Nov 18, 2024
  2. F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and DietaryE · patternCorrected Nov 18, 2024
  3. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Nov 18, 2024
  4. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Nov 18, 2024
  5. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Nov 18, 2024
  6. F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsD · isolatedCorrected Nov 18, 2024
  7. F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Nov 18, 2024
  8. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningE · patternCorrected Nov 18, 2024
  9. 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 Nov 18, 2024
  10. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Nov 18, 2024
  11. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Nov 18, 2024
  12. F685Assist a resident in gaining access to vision and hearing services.Quality of Life and CareD · isolatedCorrected Nov 18, 2024
  13. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Nov 18, 2024
  14. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Nov 18, 2024
  15. F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareE · patternCorrected Nov 18, 2024
  16. 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 Nov 18, 2024
  17. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Nov 18, 2024
  18. 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 Nov 18, 2024
  19. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceE · patternCorrected Nov 18, 2024
  20. F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Nutrition and DietaryE · patternCorrected Dec 6, 2024
  21. F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Nutrition and DietaryE · patternCorrected Nov 18, 2024
  22. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Nov 18, 2024
  23. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryJ · isolatedCorrected Nov 18, 2024
  24. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Nov 18, 2024
  25. F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Nutrition and DietaryE · patternCorrected Nov 18, 2024
  26. F814Dispose of garbage and refuse properly.Nutrition and DietaryE · patternCorrected Nov 18, 2024
  27. 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 Nov 18, 2024
  28. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Nov 18, 2024
  29. 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 ControlE · patternCorrected Nov 18, 2024
  30. F908Keep all essential equipment working safely.EnvironmentalD · isolatedCorrected Nov 18, 2024
Sep 10, 20242 citationsCycle 2worst 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 Sep 26, 2024
  2. F626Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.Resident RightsD · isolatedCorrected Sep 26, 2024
Aug 21, 20241 citationCycle 2worst 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 Sep 16, 2024
Aug 5, 20244 citationsCycle 2worst D · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Sep 23, 2024
  2. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 29, 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 ExploitationD · isolatedCorrected Aug 29, 2024
  4. F576Ensure residents have reasonable access to and privacy in their use of communication methods.Resident RightsD · isolatedCorrected Sep 23, 2024
Jul 18, 20241 citationCycle 2worst 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 20, 2024
Jun 7, 202410 citationsCycle 2worst J · immediate jeopardy$86,623, payment denial
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jul 15, 2024
  2. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Jul 15, 2024
  3. 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 Jul 15, 2024
  4. 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 ExploitationJ · isolatedCorrected Jul 15, 2024
  5. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 15, 2024
  6. 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 Jul 15, 2024
  7. F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Nursing and Physician ServicesE · patternCorrected Jul 15, 2024
  8. 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 Jul 15, 2024
  9. F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.AdministrationC · widespreadCorrected Jul 15, 2024
  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 Jul 15, 2024
Apr 10, 20242 citationsCycle 2worst D · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Apr 27, 2024
  2. 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 Apr 27, 2024
Feb 23, 20241 citationCycle 2worst 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 Mar 6, 2024
Jan 25, 20246 citationsCycle 3worst E · no actual harm
  1. 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 Feb 16, 2024
  2. F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Feb 16, 2024
  3. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Feb 16, 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 Feb 16, 2024
  5. 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 Feb 16, 2024
  6. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Feb 16, 2024
Dec 4, 20231 citationCycle 3worst G · actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareG · isolatedCorrected Dec 24, 2023
Nov 14, 20231 citationCycle 3worst 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 CareG · isolatedCorrected Dec 14, 2023
Oct 25, 20231 citationCycle 3worst 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 Nov 15, 2023
Oct 6, 202329 citationsCycle 2worst E · no actual harm
  1. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryD · isolatedCorrected Oct 30, 2023
  2. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Oct 30, 2023
  3. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Oct 30, 2023
  4. F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Oct 30, 2023
  5. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsE · patternCorrected Oct 30, 2023
  6. F576Ensure residents have reasonable access to and privacy in their use of communication methods.Resident RightsE · patternCorrected Oct 30, 2023
  7. 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 Oct 30, 2023
  8. 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 RightsE · patternCorrected Oct 30, 2023
  9. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Oct 30, 2023
  10. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Oct 30, 2023
  11. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Oct 30, 2023
  12. 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 Oct 30, 2023
  13. 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 Oct 30, 2023
  14. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Oct 30, 2023
  15. F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and CareD · isolatedCorrected Oct 30, 2023
  16. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Oct 30, 2023
  17. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Oct 30, 2023
  18. 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 Oct 30, 2023
  19. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Oct 30, 2023
  20. 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 Oct 30, 2023
  21. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Oct 30, 2023
  22. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Oct 30, 2023
  23. 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 30, 2023
  24. 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 Oct 30, 2023
  25. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Oct 30, 2023
  26. 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.AdministrationE · patternCorrected Oct 30, 2023
  27. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Oct 30, 2023
  28. F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalE · patternCorrected Oct 30, 2023
  29. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Oct 30, 2023
Sep 29, 20231 citationCycle 3worst D · no actual harm
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Oct 13, 2023
Sep 27, 20235 citationsCycle 3worst G · actual harm
  1. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Oct 31, 2023
  2. 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 Oct 31, 2023
  3. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceE · patternCorrected Oct 31, 2023
  4. F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Oct 31, 2023
  5. 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 Oct 31, 2023
Sep 22, 20231 citationCycle 3worst D · no actual harm
  1. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Oct 15, 2023
Sep 7, 20237 citationsCycle 3worst J · immediate jeopardy
  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 Oct 31, 2023
  2. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Oct 31, 2023
  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 PlanningE · patternCorrected Oct 31, 2023
  4. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Oct 31, 2023
  5. 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 ExploitationJ · isolatedCorrected Oct 31, 2023
  6. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Oct 31, 2023
  7. F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Nursing and Physician ServicesD · isolatedCorrected Oct 31, 2023
Sep 1, 20231 citationCycle 3worst D · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Sep 15, 2023
Aug 23, 20232 citationsCycle 3worst E · no actual harm$28,822, payment denial
  1. F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareE · patternCorrected Sep 8, 2023
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Sep 8, 2023
Aug 14, 20231 citationCycle 3worst D · no actual harm$28,822, payment denial
  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 Aug 21, 2023
Jul 27, 20231 citationCycle 3worst D · no actual harm
  1. 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 Aug 10, 2023
Jul 19, 20232 citationsCycle 3worst D · no actual harm
  1. F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident RightsD · isolatedCorrected Aug 10, 2023
  2. F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Aug 10, 2023
Jun 30, 20232 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 Jul 16, 2023
  2. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Jul 16, 2023
Jun 21, 20236 citationsCycle 3worst E · no actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Jul 15, 2023
  2. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Jul 15, 2023
  3. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Jul 15, 2023
  4. F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareE · patternCorrected Jul 15, 2023
  5. F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.AdministrationD · isolatedCorrected Jul 15, 2023
  6. 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 Jul 15, 2023
May 12, 20232 citationsCycle 3worst 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 May 30, 2023
  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 May 30, 2023
Apr 27, 20232 citationsCycle 3worst D · no actual harm
  1. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected May 12, 2023
  2. 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 May 12, 2023
Apr 11, 20231 citationCycle 3worst D · no actual harm
  1. F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalD · isolatedCorrected May 5, 2023
Mar 16, 20231 citationCycle 3worst D · no actual harm
  1. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 4, 2023
Feb 23, 20233 citationsCycle 3worst D · no actual harm
  1. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Mar 5, 2023
  2. 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 Mar 5, 2023
  3. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Mar 5, 2023
Feb 21, 20231 citationCycle 3worst E · no actual harm
  1. F732Post nurse staffing information every day.Nursing and Physician ServicesE · patternCorrected Mar 3, 2023
Feb 10, 20231 citationCycle 3worst D · no actual harm
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 3, 2023
Oct 28, 202217 citationsCycle 3worst G · actual harm
  1. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Dec 14, 2022
  2. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Dec 14, 2022
  3. 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 Jan 17, 2023
  4. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Dec 14, 2022
  5. 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 ServiceE · patternCorrected Dec 14, 2022
  6. 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 14, 2022
  7. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Dec 14, 2022
  8. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Dec 14, 2022
  9. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsE · patternCorrected Dec 14, 2022
  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 RightsD · isolatedCorrected Dec 14, 2022
  11. F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Dec 14, 2022
  12. 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 14, 2022
  13. 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 14, 2022
  14. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Jan 17, 2023
  15. 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 Dec 14, 2022
  16. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Dec 14, 2022
  17. 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 CareD · isolatedCorrected Dec 14, 2022

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined4.24hrsAbove 51% of peers−0.27 vs CA avg
  • Registered nursesRN hours only0.36hrsAbove only 25% of peers−0.29 vs CA avg
  • Licensed practical nursesLPN hours1.25hrs
  • Nurse aidesCNA hours2.63hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.85hrs
  • California average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better47%Above only 21% of peersCA avg 38%
  • RN turnoverRegistered nurses only60%Not ranked by CMS
  • Administrators who leftIn the past year1Leadership changed
  • Occupancy141 certified beds · ~122 residents a day87%Above only 28% of peersCA avg 88%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $297,315In fines
  • 5Fines
  • 4Payment denials
  • $26,970CA avg in fines
Above only 1% of peersFewer fines than 1% of rated homes in California

Actions on record

  1. Mar 22, 2025Civil money penalty$51,704
  2. Mar 22, 2025Denial of payment for new admissionsfrom Apr 19, 2025
  3. Oct 11, 2024Civil money penalty$17,660
  4. Oct 11, 2024Civil money penalty$112,506
  5. Oct 11, 2024Denial of payment for new admissionsfrom Nov 22, 2024
  6. Jun 7, 2024Civil money penalty$86,623
  7. Jun 7, 2024Denial of payment for new admissionsfrom Jul 9, 2024
  8. Aug 23, 2023Civil money penalty$28,822
  9. Aug 23, 2023Denial of payment for new admissionsfrom Nov 23, 2023

Ownership

As filed with CMS

Structure

Ownership type
For profit - Corporation
Chain
Serrano Group11 facilities in the chain2.5★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Lory Lynn LLC
  • Maclay Partners LLC
  • Dov Jacobs
  • Benjamin Landa
Indirect owners (5%+)
  • Howard Fensterman
  • Judah Taub
Operational or managerial control
  • Mark Donohoe
Corporate officers
  • Dov Jacobs
  • Benjamin Landa

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 555583 · 12831 MACLAY STREET, SYLMAR, CA, 91342.
  • 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.

Own or manage a facility?

Claim your free listing to correct details, reply to reviews, and show your verified badge.

Claim your facility

Read our latest articles