Nursing homes › California › Carmel Mountain Rehabilitation & Healthcare Center
11895 Avenue of Industry, San Diego, CA 92128 · 8586730101 · 120 certified beds
Per CMS filings, this facility is affiliated with The Ensign Group, a group operating 346 facilities in 17 states. Group record: average rating 3.2/5, 33 abuse citation icons, 9 facilities on the Special Focus list, $7,179,329 in federal fines. This facility rates below its group average (3.2/5).
Total nurse staffing: 5.02 (California median: 4.24). RN hours: 0.96. Weekend total: 4.61. Nursing staff turnover: 40%.
All-time on record: 53 deficiency citations. Below: citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 2026-04-15 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | complaint | corrected 2026-05-21 |
| 2026-04-15 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | complaint | corrected 2026-05-21 |
| 2026-04-15 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | complaint | corrected 2026-05-21 |
| 2026-01-22 | Provide and implement an infection prevention and control program. | E | complaint | corrected 2026-02-12 |
| 2025-09-16 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | complaint | corrected 2025-10-05 |
| 2025-09-16 | Provide and implement an infection prevention and control program. | D | complaint | corrected 2025-10-05 |
| 2025-09-04 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | complaint | corrected 2025-09-22 |
| 2025-09-04 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | complaint | corrected 2025-10-05 |
| 2025-09-04 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | D | complaint | corrected 2025-09-22 |
| 2025-04-24 | Reasonably accommodate the needs and preferences of each resident. | E | Health | corrected 2025-05-24 |
| 2025-04-24 | 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. | E | Health | corrected 2025-05-24 |
| 2025-04-24 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Health | corrected 2025-05-24 |
| 2025-04-24 | Have a plan that describes the process for conducting QAPI and QAA activities. | E | Health | corrected 2025-05-24 |
| 2025-04-24 | Provide and implement an infection prevention and control program. | E | Health | corrected 2025-05-24 |
| 2025-04-24 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | D | Health | corrected 2025-05-24 |
| 2025-04-24 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | complaint | corrected 2025-05-24 |
| 2025-04-24 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Health | corrected 2025-05-24 |
| 2025-04-24 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Health | corrected 2025-05-24 |
| 2025-04-24 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | complaint | corrected 2025-05-24 |
| 2025-04-24 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Health | corrected 2025-05-24 |
| 2025-04-24 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D | Health | corrected 2025-05-24 |
| 2025-04-24 | Implement 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. | D | Health | corrected 2025-05-24 |
| 2025-04-24 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Health | corrected 2025-05-24 |
| 2024-12-26 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E | complaint | corrected 2025-02-03 |
| 2024-10-15 | Ensure each resident receives an accurate assessment. | D | complaint | corrected 2024-11-15 |
| 2024-10-15 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D | complaint | corrected 2024-11-15 |
| 2024-09-13 | 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. | D | complaint | corrected 2024-10-15 |
| 2024-09-13 | Provide and implement an infection prevention and control program. | D | complaint | corrected 2024-10-15 |
| 2024-07-30 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | complaint | corrected 2024-08-22 |
| 2024-05-10 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Health | corrected 2024-06-21 |
| 2024-05-10 | Provide and implement an infection prevention and control program. | E | Health | corrected 2024-06-21 |
| 2024-05-10 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Health | corrected 2024-06-21 |
| 2024-05-10 | Allow residents to self-administer drugs if determined clinically appropriate. | D | Health | corrected 2024-06-21 |
| 2024-05-10 | Reasonably accommodate the needs and preferences of each resident. | D | Health | corrected 2024-06-21 |
| 2024-05-10 | 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. | D | Health | corrected 2024-06-21 |
| 2024-05-10 | Keep residents' personal and medical records private and confidential. | D | Health | corrected 2024-06-21 |
| 2024-05-10 | 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. | D | Health | corrected 2024-06-21 |
| 2024-05-10 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Health | corrected 2024-06-21 |
| 2024-05-10 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Health | corrected 2024-06-21 |
| 2024-05-10 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Health | corrected 2024-06-21 |
| Date | Type | Amount |
|---|---|---|
| 2026-04-15 | Payment Denial | 8 days payment denial |
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| BURNAM, SOON | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 09/09/2024 |
| KALAFER, MICHAEL | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 03/22/2016 |
| MATTHEWS, GLENN | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 04/01/2013 |
| PORT, BARRY | Corporate Director | Individual | NOT APPLICABLE | since 01/22/2015 |
| BURNAM, SOON | Corporate Officer | Individual | NOT APPLICABLE | since 09/09/2024 |
| KEETCH, CHAD | Corporate Officer | Individual | NOT APPLICABLE | since 03/01/2011 |
| OH, KATHERINE | Corporate Officer | Individual | NOT APPLICABLE | since 09/09/2024 |
| SATO, AMI | Corporate Officer | Individual | NOT APPLICABLE | since 09/09/2024 |
| WILLITS, ADAM | Corporate Officer | Individual | NOT APPLICABLE | since 03/01/2006 |
| CETNA STAFFING INC | Operational/Managerial Control | Organization | NOT APPLICABLE | since 03/01/2006 |
| LINCARE INC | Operational/Managerial Control | Organization | NOT APPLICABLE | since 03/01/2006 |
| SEVENOAKS CAPITAL ASSOCIATES LLC | Operational/Managerial Control | Organization | NOT APPLICABLE | since 03/01/2006 |
| KALAFER, MICHAEL | Operational/Managerial Control | Individual | NOT APPLICABLE | since 03/22/2016 |
| MATTHEWS, GLENN | Operational/Managerial Control | Individual | NOT APPLICABLE | since 04/01/2013 |
Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 555326. Corrections: data@carerecords.org.