Nursing homes › California › Monrovia Gardens Healthcare Center
615 W. Duarte Rd., Monrovia, CA 91016 · 6263584547 · 96 certified beds
Per CMS filings, this facility is affiliated with Cambridge Healthcare Services, a group operating 32 facilities in 1 states. Group record: average rating 2.5/5, 1 abuse citation icons, 1 facilities on the Special Focus list, $1,091,988 in federal fines. This facility rates below its group average (2.5/5).
Total nurse staffing: 4.38 (California median: 4.24). RN hours: 0.44. Weekend total: 3.80. Nursing staff turnover: 50%.
All-time on record: 98 deficiency citations. Below: citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 2026-03-03 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | E | complaint | corrected 2026-03-23 |
| 2026-03-03 | Provide appropriate foot care. | D | complaint | corrected 2026-03-23 |
| 2026-03-03 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D | complaint | corrected 2026-03-23 |
| 2025-12-19 | 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. | E | Health | corrected 2025-12-29 |
| 2025-12-19 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E | Health | corrected 2025-12-29 |
| 2025-12-19 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | Health | corrected 2025-12-29 |
| 2025-12-19 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Health | corrected 2025-12-29 |
| 2025-12-19 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Health | corrected 2025-12-30 |
| 2025-12-19 | Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | D | Health | corrected 2025-12-29 |
| 2025-12-19 | 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 2025-12-29 |
| 2025-12-19 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Health | corrected 2025-12-29 |
| 2025-12-19 | Provide activities to meet all resident's needs. | D | Health | corrected 2025-12-29 |
| 2025-12-19 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Health | corrected 2025-12-29 |
| 2025-12-19 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Health | corrected 2025-12-29 |
| 2025-12-19 | 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. | D | Health | corrected 2025-12-29 |
| 2025-12-19 | Provide safe and appropriate respiratory care for a resident when needed. | D | Health | corrected 2025-12-29 |
| 2025-12-19 | Provide and implement an infection prevention and control program. | D | Health | corrected 2025-12-29 |
| 2025-12-19 | Implement a program that monitors antibiotic use. | D | Health | corrected 2025-12-29 |
| 2025-10-31 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | complaint | corrected 2025-11-18 |
| 2025-09-17 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | D | complaint | corrected 2025-11-23 |
| 2025-09-03 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | complaint | corrected 2025-09-24 |
| 2025-09-03 | Reasonably accommodate the needs and preferences of each resident. | D | complaint | corrected 2025-09-23 |
| 2025-09-03 | 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 2025-09-23 |
| 2025-08-27 | Keep all essential equipment working safely. | E | complaint | corrected 2025-09-15 |
| 2025-08-05 | Reasonably accommodate the needs and preferences of each resident. | E | complaint | corrected 2025-08-27 |
| 2025-08-05 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | complaint | corrected 2025-08-30 |
| 2025-08-05 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | E | complaint | corrected 2025-08-21 |
| 2025-07-09 | Reasonably accommodate the needs and preferences of each resident. | D | complaint | corrected 2025-07-11 |
| 2025-07-09 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D | complaint | corrected 2025-06-27 |
| 2025-07-09 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | complaint | corrected 2025-07-11 |
| 2025-05-13 | Reasonably accommodate the needs and preferences of each resident. | D | complaint | corrected 2025-05-14 |
| 2025-05-13 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D | complaint | corrected 2025-05-14 |
| 2025-05-13 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | complaint | corrected 2025-05-14 |
| 2025-04-24 | Provide and implement an infection prevention and control program. | E | complaint | corrected 2025-04-25 |
| 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 2025-05-13 |
| 2025-03-27 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E | complaint | corrected 2025-04-01 |
| 2025-03-27 | Keep residents' personal and medical records private and confidential. | D | complaint | corrected 2025-04-01 |
| 2025-03-27 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | complaint | corrected 2025-04-01 |
| 2025-03-27 | Provide safe, appropriate pain management for a resident who requires such services. | D | complaint | corrected 2025-04-01 |
| 2025-03-27 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | D | complaint | corrected 2025-03-28 |
No federal fines or payment denials on record.
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| AG FACILITIES OPERATIONS, LLC | 5% Or Greater Direct Ownership Interest | Organization | 100% | since 08/11/2003 |
| IRA E SMEDRA LIVING TRUST | 5% Or Greater Indirect Ownership Interest | Organization | 48% | since 08/11/2003 |
| WIN WIN ENTERPRISES, LLC | 5% Or Greater Indirect Ownership Interest | Organization | 48% | since 08/11/2003 |
| SOHAL, JASPAL | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 10/22/2024 |
| VIDALES, MIGUEL | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 03/01/2021 |
| WINTNER, JACOB | Corporate Officer | Individual | NOT APPLICABLE | since 08/11/2003 |
| CAMBRIDGE HEALTHCARE SERVICES LLC | Operational/Managerial Control | Organization | NOT APPLICABLE | since 10/01/2013 |
| BALACUIT, DONALD | Operational/Managerial Control | Individual | NOT APPLICABLE | since 04/18/2024 |
| BUTENKO, JULIE | Operational/Managerial Control | Individual | NOT APPLICABLE | since 07/24/2023 |
| CAPELA, HEIDI | Operational/Managerial Control | Individual | NOT APPLICABLE | since 04/03/2023 |
| CRUZ, HAYLEY | Operational/Managerial Control | Individual | NOT APPLICABLE | since 04/01/2025 |
| HASSELL, LANCE | Operational/Managerial Control | Individual | NOT APPLICABLE | since 04/25/2022 |
| LUTZ, LINDA | Operational/Managerial Control | Individual | NOT APPLICABLE | since 02/01/2012 |
| SALAZAR, PAULINA | Operational/Managerial Control | Individual | NOT APPLICABLE | since 12/14/2020 |
| SMEDRA, IRA | Operational/Managerial Control | Individual | NOT APPLICABLE | since 08/11/2003 |
| SOHAL, JASPAL | Operational/Managerial Control | Individual | NOT APPLICABLE | since 10/22/2024 |
| VIDALES, MIGUEL | Operational/Managerial Control | Individual | NOT APPLICABLE | since 03/01/2021 |
| WINTNER, JACOB | Operational/Managerial Control | Individual | NOT APPLICABLE | since 08/11/2003 |
Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 055367. Corrections: data@carerecords.org.