nursing home in Monrovia, CA
Monrovia Gardens Healthcare Center
615 W. Duarte Rd., Monrovia, CA 91016 · (626) 358-4547
★★★★★1
Much below average
CMS overall star rating
CMS overall star rating
- Health inspections★★★★★1
- Staffing★★★★★3
- Quality measures★★★★★3
Source: Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. We refresh our information from this source. About our data
Monrovia Gardens Healthcare Center at a glance
Monrovia Gardens Healthcare Center is a 96-bed for-profit nursing home in Monrovia, California (Los Angeles County).
CMS gives it 1 out of 5 stars on its overall star rating, worse than the California average of 3.2.
Residents receive about 4.4 hours of nursing care per day (0.4 of them from registered nurses), close to the state average of 4.5 hours.
Its most recent standard health inspection (December 19, 2025) found 30 health citations. The California average is 15.5.
It has not received a federal fine in the past three years.
Nursing staff turnover is 50.5% per year (state average 36.7%).
Facility details
- Type
- Nursing home
- Ownership
- For Profit - Limited Liability Company
- Beds
- 96
- Certified for
- Medicare and Medicaid
- Chain / affiliated entity
- Cambridge Healthcare Services
- Medicare-certified since
- December 31, 1971
- Resident/family council
- Resident
- County
- Los Angeles County
- CMS Certification Number
- 055367
Ratings
| Measure | This facility | California avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Overall star rating ⓘ (higher is better) | 1 / 5 | 3.2 / 5 | 3 / 5 | Worse |
| Health inspection rating ⓘ (higher is better) | 1 / 5 | 2.8 / 5 | 2.8 / 5 | Worse |
| Staffing rating ⓘ (higher is better) | 3 / 5 | 3.3 / 5 | 2.9 / 5 | Average |
| Quality measures rating ⓘ (higher is better) | 3 / 5 | 4.1 / 5 | 3.6 / 5 | Worse |
| Long-stay quality rating (higher is better) | 4 / 5 | 4.4 / 5 | 3.8 / 5 | Average |
| Short-stay (rehab) quality rating (higher is better) | 2 / 5 | 3.6 / 5 | 3.3 / 5 | Worse |
Staffing
| Measure | This facility | California avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Total nurse staff hours per resident per day ⓘ (higher is better) | 4.38 hrs | 4.52 hrs | 3.86 hrs | Better |
| Registered nurse hours per resident per day (higher is better) | 0.44 hrs | 0.67 hrs | 0.69 hrs | Worse |
| Nurse aide hours per resident per day (higher is better) | 2.71 hrs | 2.65 hrs | 2.32 hrs | Better |
| Weekend nurse staff hours per resident per day (higher is better) | 3.80 hrs | 4.09 hrs | 3.42 hrs | Better |
| Nursing staff turnover (yearly) (lower is better) | 50.5% | 36.7% | 45.8% | Worse |
| Registered nurse turnover (yearly) (lower is better) | 50% | 38.1% | 42.9% | Worse |
| Administrators who left in the past year (lower is better) | 1 | 0 | 1 | Worse |
Inspections
| Measure | This facility | California avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Health citations in the most recent inspection (lower is better) | 30 | 16 | 9 | Worse |
| Citations from complaint investigations (latest cycle) (lower is better) | 15 | 4 | 3 | Worse |
| Weighted health inspection score ⓘ (lower is better) | 194 | 105.8 | 80.6 | Worse |
Penalties
| Measure | This facility | California avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Fines in the past 3 years (lower is better) | 0 | 1 | 1 | Better |
| Total fines in the past 3 years (lower is better) | $0 | $23,986 | $30,972 | Better |
| All federal penalties in the past 3 years (lower is better) | 0 | 1 | 1 | Better |
Size
| Measure | This facility | California avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Certified beds | 96 | 99 | 107 | |
| Average residents per day | 80 | 88 | 86 | |
| Occupancy | 82.9% | 88.4% | 80.9% |
Long-stay residents
| Measure | This facility | California avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Long-stay residents with a fall causing major injury (lower is better) | 1.5% | 1.6% | 3.2% | Better |
| Long-stay residents with pressure ulcers (lower is better) | 5.2% | 4.3% | 4.6% | Worse |
| Long-stay residents given antipsychotic medication (lower is better) | 18.7% | 12% | 15.4% | Worse |
| Long-stay residents with a urinary tract infection (lower is better) | 0.4% | 1.2% | 1.6% | Better |
| Long-stay residents with a catheter left in the bladder (lower is better) | 0% | 0.8% | 0.8% | Better |
| Long-stay residents needing more help with daily activities (lower is better) | 9.4% | 10.2% | 13.9% | Better |
| Long-stay residents whose walking worsened (lower is better) | 11.2% | 9.8% | 14.1% | Better |
| Long-stay residents who lose too much weight (lower is better) | 5.2% | 4% | 5.2% | Average |
| Long-stay residents with depressive symptoms (lower is better) | 21.5% | 7.3% | 12.8% | Worse |
| Long-stay residents who were physically restrained (lower is better) | 0% | 0.4% | 0.1% | Better |
| Long-stay residents given anti-anxiety or sleep medication (lower is better) | 7.9% | 13.7% | 19.5% | Better |
| Long-stay residents with new or worse incontinence (lower is better) | 7.2% | 10.2% | 19% | Better |
| Long-stay residents given a flu vaccine (higher is better) | 100% | 98.2% | 95.5% | Average |
| Long-stay residents given a pneumonia vaccine (higher is better) | 100% | 98.6% | 93.6% | Better |
Short-stay residents
| Measure | This facility | California avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Short-stay residents newly given antipsychotic medication (lower is better) | 0.9% | 1.5% | 1.6% | Better |
| Short-stay residents given a flu vaccine (higher is better) | 97.3% | 93.2% | 79.8% | Better |
| Short-stay residents given a pneumonia vaccine (higher is better) | 100% | 94.4% | 82% | Better |
Inspection citations
State inspectors cited this home for 104 health deficiencies and 15 fire safety deficiencies in the inspection records CMS currently publishes. 1 citation involved actual harm.
| Date | Citation | Severity | Status |
|---|---|---|---|
| July 15, 2026 Complaint | Develop 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 Planning Deficiencies · Tag F0656 | D Potential harm, isolated | Deficient, Provider has no plan of correction |
| July 8, 2026 Complaint | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · Tag F0919 | D Potential harm, isolated | Deficient, Provider has no plan of correction |
| July 8, 2026 Complaint | Ensure 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 Dietary Deficiencies · Tag F0803 | D Potential harm, isolated | Deficient, Provider has no plan of correction |
| July 8, 2026 Complaint | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Tag F0677 | D Potential harm, isolated | Deficient, Provider has no plan of correction |
| June 23, 2026 Complaint | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Tag F0757 | E Potential harm, pattern | Corrected June 25, 2026 |
| June 23, 2026 Complaint | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Tag F0552 | D Potential harm, isolated | Corrected July 13, 2026 |
| June 4, 2026 Complaint | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · Tag F0676 | D Potential harm, isolated | Corrected June 5, 2026 |
| March 3, 2026 Complaint | Develop 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 Planning Deficiencies · Tag F0657 | E Potential harm, pattern | Corrected March 23, 2026 |
| March 3, 2026 Complaint | Provide appropriate foot care. Quality of Life and Care Deficiencies · Tag F0687 | D Potential harm, isolated | Corrected March 23, 2026 |
| March 3, 2026 Complaint | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Tag F0698 | D Potential harm, isolated | Corrected March 23, 2026 |
| December 19, 2025 Fire safety | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Tag K0761 | F Potential harm, widespread | Corrected December 19, 2025 |
| December 19, 2025 Fire safety | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Tag K0345 | F Potential harm, widespread | Corrected December 19, 2025 |
| December 19, 2025 Fire safety | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0918 | F Potential harm, widespread | Corrected December 19, 2025 |
| December 19, 2025 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | E Potential harm, pattern | Corrected December 19, 2025 |
| December 19, 2025 Fire safety | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Tag K0321 | D Potential harm, isolated | Corrected December 19, 2025 |
| December 19, 2025 Fire safety | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. Smoke Deficiencies · Tag K0342 | D Potential harm, isolated | Corrected December 19, 2025 |
| December 19, 2025 Fire safety | Install an approved automatic sprinkler system. Smoke Deficiencies · Tag K0351 | D Potential harm, isolated | Corrected December 19, 2025 |
| December 19, 2025 Standard | Honor 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 Rights Deficiencies · Tag F0578 | E Potential harm, pattern | Corrected December 29, 2025 |
| December 19, 2025 Standard | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | E Potential harm, pattern | Corrected December 29, 2025 |
| December 19, 2025 Standard | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Tag F0755 | E Potential harm, pattern | Corrected December 29, 2025 |
| December 19, 2025 Standard | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | E Potential harm, pattern | Corrected December 29, 2025 |
| December 19, 2025 Standard | Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0606 | D Potential harm, isolated | Corrected December 29, 2025 |
| December 19, 2025 Standard | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Tag F0695 | D Potential harm, isolated | Corrected December 29, 2025 |
| December 19, 2025 Standard | Ensure 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 Care Deficiencies · Tag F0693 | D Potential harm, isolated | Corrected December 29, 2025 |
| December 19, 2025 Standard | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | D Potential harm, isolated | Corrected December 29, 2025 |
| December 19, 2025 Standard | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Tag F0686 | D Potential harm, isolated | Corrected December 29, 2025 |
| December 19, 2025 Standard | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Tag F0550 | D Potential harm, isolated | Corrected December 30, 2025 |
| December 19, 2025 Standard | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Tag F0679 | D Potential harm, isolated | Corrected December 29, 2025 |
| December 19, 2025 Standard | Develop 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 Planning Deficiencies · Tag F0657 | D Potential harm, isolated | Corrected December 29, 2025 |
| December 19, 2025 Standard | Implement a program that monitors antibiotic use. Infection Control Deficiencies · Tag F0881 | D Potential harm, isolated | Corrected December 29, 2025 |
| December 19, 2025 Standard | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | D Potential harm, isolated | Corrected December 29, 2025 |
| December 19, 2025 Standard | Develop 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 Planning Deficiencies · Tag F0656 | D Potential harm, isolated | Corrected December 29, 2025 |
| October 31, 2025 Complaint | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 | D Potential harm, isolated | Corrected November 18, 2025 |
| September 17, 2025 Complaint | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Resident Rights Deficiencies · Tag F0557 | D Potential harm, isolated | Corrected November 23, 2025 |
| September 3, 2025 Complaint | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Tag F0677 | E Potential harm, pattern | Corrected September 24, 2025 |
| September 3, 2025 Complaint | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Nutrition and Dietary Deficiencies · Tag F0808 | D Potential harm, isolated | Corrected September 23, 2025 |
| September 3, 2025 Complaint | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Tag F0558 | D Potential harm, isolated | Corrected September 23, 2025 |
| August 27, 2025 Complaint | Keep all essential equipment working safely. Environmental Deficiencies · Tag F0908 | E Potential harm, pattern | Corrected September 15, 2025 |
| August 5, 2025 Complaint | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Tag F0558 | E Potential harm, pattern | Corrected August 27, 2025 |
| August 5, 2025 Complaint | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Tag F0867 | E Potential harm, pattern | Corrected August 21, 2025 |
| August 5, 2025 Complaint | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Tag F0677 | E Potential harm, pattern | Corrected August 30, 2025 |
| July 9, 2025 Complaint | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Tag F0558 | D Potential harm, isolated | Corrected July 11, 2025 |
| July 9, 2025 Complaint | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | D Potential harm, isolated | Corrected July 11, 2025 |
| July 9, 2025 Complaint | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0604 | D Potential harm, isolated | Corrected June 27, 2025 |
| May 13, 2025 Complaint | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Tag F0677 | D Potential harm, isolated | Corrected May 14, 2025 |
| May 13, 2025 Complaint | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0607 | D Potential harm, isolated | Corrected May 14, 2025 |
| May 13, 2025 Complaint | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Tag F0558 | D Potential harm, isolated | Corrected May 14, 2025 |
| April 24, 2025 Complaint | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | E Potential harm, pattern | Corrected April 25, 2025 |
| April 24, 2025 Complaint | Develop 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 Planning Deficiencies · Tag F0656 | D Potential harm, isolated | Corrected May 13, 2025 |
| March 27, 2025 Complaint | Provide 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 Services Deficiencies · Tag F0725 | E Potential harm, pattern | Corrected April 1, 2025 |
| March 27, 2025 Complaint | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Tag F0677 | D Potential harm, isolated | Corrected April 1, 2025 |
| March 27, 2025 Complaint | Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. Nutrition and Dietary Deficiencies · Tag F0807 | D Potential harm, isolated | Corrected March 28, 2025 |
| March 27, 2025 Complaint | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · Tag F0806 | D Potential harm, isolated | Corrected March 28, 2025 |
| March 27, 2025 Complaint | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Tag F0697 | D Potential harm, isolated | Corrected April 1, 2025 |
| March 27, 2025 Complaint | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Tag F0583 | D Potential harm, isolated | Corrected April 1, 2025 |
| February 26, 2025 Complaint | Provide 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 Care Deficiencies · Tag F0688 | E Potential harm, pattern | Corrected March 20, 2025 |
| February 26, 2025 Complaint | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Tag F0842 | E Potential harm, pattern | Corrected March 20, 2025 |
| February 26, 2025 Complaint | Honor 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 Rights Deficiencies · Tag F0584 | D Potential harm, isolated | Corrected March 21, 2025 |
| February 10, 2025 Complaint | Develop 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 Planning Deficiencies · Tag F0656 | D Potential harm, isolated | Corrected February 12, 2025 |
| January 24, 2025 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | G Actual harm, isolated | Corrected February 20, 2025 |
| January 24, 2025 Complaint | Provide 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 Services Deficiencies · Tag F0725 | E Potential harm, pattern | Corrected January 27, 2025 |
| January 24, 2025 Complaint | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Tag F0677 | E Potential harm, pattern | Corrected February 12, 2025 |
| January 24, 2025 Complaint | Ensure 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 Services Deficiencies · Tag F0726 | D Potential harm, isolated | Corrected January 29, 2025 |
| January 24, 2025 Complaint | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | D Potential harm, isolated | Corrected February 20, 2025 |
| January 24, 2025 Complaint | Ensure residents have reasonable access to and privacy in their use of communication methods. Resident Rights Deficiencies · Tag F0576 | D Potential harm, isolated | Corrected January 29, 2025 |
| January 24, 2025 Complaint | Develop 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 Planning Deficiencies · Tag F0656 | D Potential harm, isolated | Corrected January 29, 2025 |
| December 31, 2024 Complaint | Provide 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 Services Deficiencies · Tag F0725 | E Potential harm, pattern | Corrected January 2, 2025 |
| December 24, 2024 Complaint | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | D Potential harm, isolated | Corrected December 26, 2024 |
| December 24, 2024 Complaint | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Tag F0550 | D Potential harm, isolated | Corrected January 14, 2025 |
| November 25, 2024 Complaint | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 | D Potential harm, isolated | Corrected November 28, 2024 |
| October 31, 2024 Fire safety | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0918 | F Potential harm, widespread | Corrected November 30, 2024 |
| October 31, 2024 Fire safety | Implement emergency and standby power systems. Emergency Preparedness Deficiencies · Tag E0041 | F Potential harm, widespread | Corrected November 30, 2024 |
| October 31, 2024 Fire safety | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Tag K0291 | F Potential harm, widespread | Corrected November 30, 2024 |
| October 31, 2024 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | F Potential harm, widespread | Corrected November 30, 2024 |
| October 31, 2024 Fire safety | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0920 | E Potential harm, pattern | Corrected November 30, 2024 |
| October 31, 2024 Fire safety | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Tag K0321 | E Potential harm, pattern | Corrected November 30, 2024 |
| October 31, 2024 Standard | Honor 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 Rights Deficiencies · Tag F0578 | E Potential harm, pattern | Corrected November 18, 2024 |
| October 31, 2024 Standard | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Tag F0558 | E Potential harm, pattern | Corrected October 31, 2024 |
| October 31, 2024 Standard | Provide 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 Care Deficiencies · Tag F0690 | E Potential harm, pattern | Corrected November 20, 2024 |
| October 31, 2024 Standard | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | E Potential harm, pattern | Corrected November 4, 2024 |
| October 31, 2024 Standard | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | E Potential harm, pattern | Corrected November 15, 2024 |
| October 31, 2024 Standard | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Tag F0684 | E Potential harm, pattern | Corrected November 20, 2024 |
| October 31, 2024 Standard | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Tag F0686 | E Potential harm, pattern | Corrected November 20, 2024 |
| October 31, 2024 Standard | Provide 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 Services Deficiencies · Tag F0725 | E Potential harm, pattern | Corrected November 5, 2024 |
| October 31, 2024 Standard | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Tag F0580 | D Potential harm, isolated | Corrected November 18, 2024 |
| October 31, 2024 Standard | Provide routine and 24-hour emergency dental care for each resident. Quality of Life and Care Deficiencies · Tag F0790 | D Potential harm, isolated | Corrected November 19, 2024 |
| October 31, 2024 Standard | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Tag F0692 | D Potential harm, isolated | Corrected November 15, 2024 |
| October 31, 2024 Standard | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · Tag F0676 | D Potential harm, isolated | Corrected November 18, 2024 |
| October 31, 2024 Standard | Develop 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 Planning Deficiencies · Tag F0656 | D Potential harm, isolated | Corrected November 24, 2024 |
| October 31, 2024 Standard | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Tag F0641 | D Potential harm, isolated | Corrected November 19, 2024 |
| October 31, 2024 Standard | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Resident Rights Deficiencies · Tag F0625 | D Potential harm, isolated | Corrected November 20, 2024 |
| October 31, 2024 Standard | Ensure 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 Dietary Deficiencies · Tag F0803 | D Potential harm, isolated | Corrected November 1, 2024 |
| October 31, 2024 Standard | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Tag F0550 | D Potential harm, isolated | Corrected November 18, 2024 |
| October 31, 2024 Standard | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · Tag F0919 | D Potential harm, isolated | Corrected November 19, 2024 |
| June 21, 2024 Complaint | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 | D Potential harm, isolated | Corrected June 27, 2024 |
| May 29, 2024 Complaint | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Tag F0580 | D Potential harm, isolated | Corrected August 2, 2024 |
| May 9, 2024 Complaint | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Infection Control Deficiencies · Tag F0882 | E Potential harm, pattern | Corrected May 10, 2024 |
| May 9, 2024 Complaint | Provide 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 Care Deficiencies · Tag F0688 | D Potential harm, isolated | Corrected May 15, 2024 |
| May 9, 2024 Complaint | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | D Potential harm, isolated | Corrected May 9, 2024 |
| October 19, 2023 Fire safety | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Tag K0321 | F Potential harm, widespread | Corrected November 11, 2023 |
| October 19, 2023 Fire safety | Install a fire alarm system that can be heard throughout the facility. Smoke Deficiencies · Tag K0341 | D Potential harm, isolated | Corrected November 11, 2023 |
| October 19, 2023 Standard | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | E Potential harm, pattern | Corrected November 14, 2023 |
| October 19, 2023 Standard | Ensure 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 Service Deficiencies · Tag F0761 | E Potential harm, pattern | Corrected November 14, 2023 |
| October 19, 2023 Standard | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | E Potential harm, pattern | Corrected November 14, 2023 |
| October 19, 2023 Standard | Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · Tag F0685 | D Potential harm, isolated | Corrected November 14, 2023 |
| October 19, 2023 Standard | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Tag F0658 | D Potential harm, isolated | Corrected November 14, 2023 |
| October 19, 2023 Standard | Develop 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 Planning Deficiencies · Tag F0657 | D Potential harm, isolated | Corrected November 14, 2023 |
| October 19, 2023 Standard | Develop 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 Planning Deficiencies · Tag F0656 | D Potential harm, isolated | Corrected November 14, 2023 |
| October 19, 2023 Standard | Provide timely, quality laboratory services/tests to meet the needs of residents. Administration Deficiencies · Tag F0770 | D Potential harm, isolated | Corrected November 14, 2023 |
| October 19, 2023 Complaint | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Tag F0550 | D Potential harm, isolated | Corrected November 14, 2023 |
| October 19, 2023 Standard | Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Administration Deficiencies · Tag F0773 | D Potential harm, isolated | Corrected November 14, 2023 |
| October 19, 2023 Standard | Provide or get specialized rehabilitative services as required for a resident. Quality of Life and Care Deficiencies · Tag F0825 | D Potential harm, isolated | Corrected November 14, 2023 |
| October 19, 2023 Standard | Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Administration Deficiencies · Tag F0837 | D Potential harm, isolated | Corrected November 14, 2023 |
| October 19, 2023 Standard | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Tag F0645 | D Potential harm, isolated | Corrected November 14, 2023 |
| October 19, 2023 Standard | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Tag F0759 | D Potential harm, isolated | Corrected November 14, 2023 |
| October 19, 2023 Standard | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Tag F0756 | D Potential harm, isolated | Corrected November 14, 2023 |
| October 19, 2023 Standard | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Tag F0692 | D Potential harm, isolated | Corrected November 14, 2023 |
| October 19, 2023 Standard | Provide 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 Care Deficiencies · Tag F0690 | D Potential harm, isolated | Corrected November 14, 2023 |
| October 11, 2023 Complaint | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 | E Potential harm, pattern | Corrected October 25, 2023 |
Severity letters follow the CMS scope-and-severity grid: A–C no actual harm with potential for minimal harm; D–F potential for more than minimal harm; G–I actual harm; J–L immediate jeopardy to resident health or safety. How to read inspection citations.
Fines and payment denials
CMS reports no federal fines or payment denials in the past three years.
Owners and managers
Individuals and organizations reported to CMS as owning or operating this nursing home.
| Name | Role | Share | Since |
|---|---|---|---|
| AG FACILITIES OPERATIONS, LLC Organization | 5% or greater direct ownership interest | 100% | 08/11/2003 |
| IRA E SMEDRA LIVING TRUST Organization | 5% or greater indirect ownership interest | 48% | 08/11/2003 |
| WIN WIN ENTERPRISES, LLC Organization | 5% or greater indirect ownership interest | 48% | 08/11/2003 |
| 615 W. DUARTE, LLC Organization | adp of the snf | NOT APPLICABLE | 10/01/2003 |
| BALACUIT, DONALD Individual | adp of the snf | NOT APPLICABLE | 04/18/2024 |
| BUTENKO, JULIE Individual | adp of the snf | NOT APPLICABLE | 07/24/2023 |
| CAMBRIDGE HEALTHCARE SERVICES LLC Organization | adp of the snf | NOT APPLICABLE | 10/24/2025 |
| CAPELA, HEIDI Individual | adp of the snf | NOT APPLICABLE | 04/03/2023 |
| HASSELL, LANCE Individual | adp of the snf | NOT APPLICABLE | 04/25/2022 |
| LUTZ, LINDA Individual | adp of the snf | NOT APPLICABLE | 02/01/2012 |
| SALAZAR, PAULINA Individual | adp of the snf | NOT APPLICABLE | 12/14/2020 |
| SMEDRA, IRA Individual | adp of the snf | NOT APPLICABLE | 08/11/2003 |
| SOHAL, JASPAL Individual | adp of the snf | NOT APPLICABLE | 10/24/2025 |
| VIDALES, MIGUEL Individual | adp of the snf | NOT APPLICABLE | 03/01/2021 |
| WINTNER, JACOB Individual | adp of the snf | NOT APPLICABLE | 08/11/2003 |
| WIN WIN ENTERPRISES, LLC Organization | adp of the snf | NOT APPLICABLE | 10/01/2003 |
| WINTNER, JACOB Individual | corporate officer | NOT APPLICABLE | 08/11/2003 |
| SOHAL, JASPAL Individual | managing control - governing body | NOT APPLICABLE | 10/22/2024 |
| VIDALES, MIGUEL Individual | managing control - governing body | NOT APPLICABLE | 03/01/2021 |
| BALACUIT, DONALD Individual | operational/managerial control | NOT APPLICABLE | 04/18/2024 |
| BUTENKO, JULIE Individual | operational/managerial control | NOT APPLICABLE | 07/24/2023 |
| CAMBRIDGE HEALTHCARE SERVICES LLC Organization | operational/managerial control | NOT APPLICABLE | 10/01/2013 |
| CAPELA, HEIDI Individual | operational/managerial control | NOT APPLICABLE | 04/03/2023 |
| CRUZ, HAYLEY Individual | operational/managerial control | NOT APPLICABLE | 04/01/2025 |
| HASSELL, LANCE Individual | operational/managerial control | NOT APPLICABLE | 04/25/2022 |
| LUTZ, LINDA Individual | operational/managerial control | NOT APPLICABLE | 02/01/2012 |
| SALAZAR, PAULINA Individual | operational/managerial control | NOT APPLICABLE | 12/14/2020 |
| SMEDRA, IRA Individual | operational/managerial control | NOT APPLICABLE | 08/11/2003 |
| SOHAL, JASPAL Individual | operational/managerial control | NOT APPLICABLE | 10/22/2024 |
| VIDALES, MIGUEL Individual | operational/managerial control | NOT APPLICABLE | 03/01/2021 |
| WINTNER, JACOB Individual | operational/managerial control | NOT APPLICABLE | 08/11/2003 |
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Frequently asked questions
What is Monrovia Gardens Healthcare Center's rating?
Monrovia Gardens Healthcare Center has 1 out of 5 stars on the CMS overall star rating. The average for California nursing homes is 3.2 stars.
How many inspection citations did Monrovia Gardens Healthcare Center receive?
Its most recent standard health inspection found 30 citations, compared with a California average of 15.5. Every citation is listed on this page with its severity.
Does Monrovia Gardens Healthcare Center accept Medicare and Medicaid?
CMS lists it as certified for: Medicare and Medicaid. Call the facility to confirm bed availability and whether it accepts your specific plan.
Who owns Monrovia Gardens Healthcare Center?
It is for profit - limited liability company and part of Cambridge Healthcare Services. The ownership section on this page lists the owners and managers reported to CMS.
Where is Monrovia Gardens Healthcare Center and how do I contact it?
Monrovia Gardens Healthcare Center is at 615 W. Duarte Rd., Monrovia, CA 91016. Phone: (626) 358-4547.
About this data
Ratings and measures come from the Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. They're based on state inspections, patient surveys and facility reports, and they describe the past. Facilities change, so visit in person and confirm details directly. About our data · Spotted an error? Let us know.