Cycle 1
Health 2025-07-31 · Fire 2025-07-31
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fontana, CA
Citrus Nursing Center
5-star overall rating with 4-star inspections with $7,446 in total fines with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
9440 Citrus Ave, Fontana, CA
(909) 823-3481
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
89
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
David & Frank Johnson
Operator or chain grouping
Approved since
1968-01-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
45 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.36
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.25
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.49
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.09
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.61
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.79
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
3.68
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,389
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9977
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.11
Baseline 21.20% · Performance 20.46% · Measure score 2.11 · Achievement 2.11 · Improvement 1.28
Healthcare-associated infections
5.78
Baseline 11.04% · Performance 7.24% · Measure score 5.78 · Achievement 1.98 · Improvement 5.78
Total nurse turnover
6.84
Baseline 65.22% · Performance 35.71% · Measure score 6.84 · Achievement 6.84 · Improvement 6.81
Adjusted total nurse staffing
3.11
Baseline 4.22 hours · Performance 3.96 hours · Measure score 3.11 · Achievement 3.11 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.76% |
10.72%
2 pts better
|
No Different than the National Rate · Eligible stays 142 · Observed rate 7.04% · Lower 95% interval 6.16% |
| Discharge to community | 52.08% |
50.57%
1.5 pts better
|
No Different than the National Rate · Eligible stays 124 · Observed rate 40.32% · Lower 95% interval 42.89% |
| Medicare spending per beneficiary | 1.32 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 95.93% |
95.27%
0.7 pts better
|
Numerator 236 · Denominator 246 |
| Falls with major injury | 0.41% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 246 |
| Discharge self-care score | 56.83% |
53.69%
3.1 pts better
|
Numerator 79 · Denominator 139 |
| Discharge mobility score | 49.64% |
50.94%
1.3 pts worse
|
Numerator 69 · Denominator 139 |
| Pressure ulcers or injuries, new or worsened | 2.44% |
2.29%
0.1 pts worse
|
Numerator 6 · Denominator 246 · Adjusted rate 2.02% |
| Healthcare-associated infections requiring hospitalization | 7.24% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 106 · Observed rate 7.55% · Lower 95% interval 4.57% |
| Staff COVID-19 vaccination coverage | 5.04% |
8.2%
3.2 pts worse
|
Numerator 6 · Denominator 119 |
| Staff flu vaccination coverage | 75.77% |
42%
33.8 pts better
|
Numerator 197 · Denominator 260 |
| Discharge function score | 56.83% |
56.45%
0.4 pts better
|
Numerator 79 · Denominator 139 |
| Transfer of health information to provider | 99.38% |
95.95%
3.4 pts better
|
Numerator 161 · Denominator 162 |
| Transfer of health information to patient | 73.33% |
96.28%
23 pts worse
|
Numerator 22 · Denominator 30 |
| Resident COVID-19 vaccinations up to date | 17.14% |
25.2%
8.1 pts worse
|
Numerator 24 · Denominator 140 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.4 |
2.3
1.1 pts worse
|
1.9
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 5.3 · Expected 3.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.7 |
1.6
2.1 pts worse
|
1.8
1.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.7 · Observed 4.4 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
1.6%
0.4 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 0.0% · Q4 1.7% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.9% |
6.8%
4.1 pts worse
|
11.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 5.5% · Q3 14.0% · Q4 22.2% · 4Q avg 10.9% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
4.1%
0.8 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.8% · Q3 3.6% · Q4 2.0% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.0% |
13.7%
4.7 pts better
|
19.6%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 8.8% · Q3 8.8% · Q4 8.5% · 4Q avg 9.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.1% |
14.2%
9.1 pts better
|
16.7%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 7.1% · Q3 5.9% · Q4 2.7% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.3% |
11.0%
2.7 pts better
|
16.3%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.9% |
10.7%
2.8 pts better
|
14.9%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 4.0% · Q3 5.8% · Q4 8.9% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.2%
0.8 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 2.6% |
10.9%
8.3 pts better
|
19.8%
17.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 3.9% · Q4 2.1% · 4Q avg 2.6% |
| Percentage of long-stay residents with pressure ulcers | 1.0% |
4.7%
3.7 pts better
|
5.1%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
94.0%
5.4 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 99.5% · Q3 99.5% · Q4 99.5% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.4% |
11.2%
1.8 pts better
|
12.0%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.4% · Observed 9.9% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.0% |
93.2%
4.8 pts better
|
79.7%
18.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.2% |
23.2%
1 pts better
|
23.9%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.2% · Observed 23.4% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-10 · Fire 2022-06-10
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2019-08-23 · Fire 2019-08-23
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-31
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-07-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-14
F · Potential for more than minimal harm
2025-07-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-31
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-07-31
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-31
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-07-31
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-08-15
F · Potential for more than minimal harm
2022-06-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-07-07
E · Potential for more than minimal harm
2022-06-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-07-07
E · Potential for more than minimal harm
2022-06-10
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2022-07-07
D · Potential for more than minimal harm
2022-06-10
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2022-07-07
D · Potential for more than minimal harm
2022-06-10
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-07-07
D · Potential for more than minimal harm
2022-06-10
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2022-07-07
D · Potential for more than minimal harm
2022-06-10
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2022-07-07
D · Potential for more than minimal harm
2022-06-10
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-07-07
D · Potential for more than minimal harm
2022-06-10
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-07-07
D · Potential for more than minimal harm
2022-06-10
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-07-07
D · Potential for more than minimal harm
2022-06-10
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2022-07-07
D · Potential for more than minimal harm
2022-06-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-07
C · Minimal harm
2022-06-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-07-07
F · Potential for more than minimal harm
2019-08-23
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-10-07
D · Potential for more than minimal harm
2019-08-23
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2019-10-07
D · Potential for more than minimal harm
2019-08-23
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2019-10-07
D · Potential for more than minimal harm
2019-08-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-10-07
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-22
E · Potential for more than minimal harm
2025-07-31
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-31
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-31
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-31
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-31
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-31
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-08-22
D · Potential for more than minimal harm
2024-12-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-17
J · Immediate jeopardy
2023-08-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-23
E · Potential for more than minimal harm
2022-06-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-07-06
D · Potential for more than minimal harm
2022-06-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-07-06
D · Potential for more than minimal harm
2022-06-10
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2022-07-06
D · Potential for more than minimal harm
2022-06-10
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-07-06
D · Potential for more than minimal harm
2022-06-10
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2022-07-06
D · Potential for more than minimal harm
2022-06-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-07-06
D · Potential for more than minimal harm
2022-06-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-06
F · Potential for more than minimal harm
2019-08-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-09-20
D · Potential for more than minimal harm
2019-08-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-09-20
D · Potential for more than minimal harm
2019-08-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-09-20
D · Potential for more than minimal harm
2019-08-23
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2019-09-20
D · Potential for more than minimal harm
2019-08-23
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-09-20
D · Potential for more than minimal harm
2019-08-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-09-20
Penalties and ownership
What sits behind the stars
$7,446
2023-08-30
Fine
Fine · fine $7,446
Fine
Ownership
Johnson, Frank
5% Or Greater Indirect Ownership Interest · Individual
Bernard-Butler, Esther
Operational/Managerial Control · Individual
Citrus Nursing Center
5% Or Greater Direct Ownership Interest · Organization
Citrus Nursing Center
Operational/Managerial Control · Organization
De Jesus, Walter
Operational/Managerial Control · Individual
Dehghanmanesh, Adrian
Operational/Managerial Control · Individual
Dehghanmanesh, Adrian
Corporate Officer · Individual
Golboo, Sepehr
Operational/Managerial Control · Individual
Johnson, Frank
Operational/Managerial Control · Individual
Johnson, Frank
Corporate Director · Individual
Kochek, Joshua
Operational/Managerial Control · Individual
Marmur, Eli
5% Or Greater Direct Ownership Interest · Individual
Oxford, Micheal
Operational/Managerial Control · Individual
Oxford, Micheal
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Laurel Convalescent Hospital
Fontana, CA
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Rialto Post Acute Center
Rialto, CA
2-star overall rating with 1-star inspections with $31,881 in total fines with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Riverside Heights Healthcare Center, LLC
Riverside, CA
5-star overall rating with 5-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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