Cycle 1
Health 2025-05-09 · Fire 2025-05-09
11 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Los Angeles, CA
College Vista Post-Acute
2-star overall rating with 2-star inspections with $43,568 in total fines with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
4681 Eagle Rock Blvd., Los Angeles, CA
(323) 257-8151
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
49
Certified beds
Average residents
43
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
David & Frank Johnson
Operator or chain grouping
Approved since
1976-07-02
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
0.23
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.51
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.68
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.43
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.75
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.96
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.21
CMS adjusted RN staffing hours
Adjusted total hours
4.06
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
38%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,348
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9833
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.08
Baseline 20.41% · Performance 20.47% · Measure score 2.08 · Achievement 2.08 · Improvement 0
Healthcare-associated infections
0
Baseline 6.37% · Performance 9.81% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.55
Baseline 62.82% · Performance 49.15% · Measure score 3.55 · Achievement 3.55 · Improvement 3.1
Adjusted total nurse staffing
3.94
Baseline 3.60 hours · Performance 4.20 hours · Measure score 3.94 · Achievement 3.94 · Improvement 2.23
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.88% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 95 · Observed rate 14.74% · Lower 95% interval 8.52% |
| Discharge to community | 41.32% |
50.57%
9.2 pts worse
|
No Different than the National Rate · Eligible stays 110 · Observed rate 29.09% · Lower 95% interval 30.96% |
| Medicare spending per beneficiary | 1.44 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 99.16% |
95.27%
3.9 pts better
|
Numerator 118 · Denominator 119 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 119 |
| Discharge self-care score | 63.51% |
53.69%
9.8 pts better
|
Numerator 47 · Denominator 74 |
| Discharge mobility score | 60.81% |
50.94%
9.9 pts better
|
Numerator 45 · Denominator 74 |
| Pressure ulcers or injuries, new or worsened | 5.04% |
2.29%
2.8 pts worse
|
Numerator 6 · Denominator 119 · Adjusted rate 4.48% |
| Healthcare-associated infections requiring hospitalization | 9.81% |
7.12%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 77 · Observed rate 16.88% · Lower 95% interval 6.35% |
| Staff COVID-19 vaccination coverage | 16.3% |
8.2%
8.1 pts better
|
Numerator 15 · Denominator 92 |
| Staff flu vaccination coverage | 60% |
42%
18 pts better
|
Numerator 57 · Denominator 95 |
| Discharge function score | 59.46% |
56.45%
3 pts better
|
Numerator 44 · Denominator 74 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 67 · Denominator 67 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25.35% |
25.2%
0.2 pts better
|
Numerator 18 · Denominator 71 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.3
0.6 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 6.0 · Expected 3.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.6
0.2 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.6 · Expected 2.4 · 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 | 3.6% |
1.6%
2 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.1% · Q3 5.9% · Q4 2.7% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.4% |
6.8%
2.6 pts worse
|
11.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 13.8% · Q3 10.7% · Q4 9.1% · 4Q avg 9.4% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
4.1%
4.1 pts better
|
5.4%
5.4 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 who received an antianxiety or hypnotic medication | 7.4% |
13.7%
6.3 pts better
|
19.6%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 3.2% · Q3 8.8% · Q4 8.1% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.4% |
14.2%
4.8 pts better
|
16.7%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 13.6% · Q3 4.8% · Q4 0.0% · 4Q avg 9.4% · 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 | 8.0% |
11.0%
3 pts better
|
16.3%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.6% |
10.7%
4.9 pts worse
|
14.9%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 14.3% · Q3 16.7% · Q4 18.2% · 4Q avg 15.6% · 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 | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 4.3% |
10.9%
6.6 pts better
|
19.8%
15.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 4.5% · Q3 3.1% · Q4 0.0% · 4Q avg 4.3% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
4.7%
0.9 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 4.6% · Q3 7.5% · Q4 3.5% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.0% |
11.2%
8.2 pts better
|
12.0%
9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.0% · Observed 3.2% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.5%
0.8 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 0.0% · Q4 5.9% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.2%
6.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.7% |
23.2%
0.5 pts worse
|
23.9%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 29.0% · Expected 29.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-06 · Fire 2024-05-06
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-11-19 · Fire 2021-11-19
10 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-05-09
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-05-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-05-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-30
E · Potential for more than minimal harm
2024-05-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-05-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-29
F · Potential for more than minimal harm
2021-11-19
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-01-06
F · Potential for more than minimal harm
2021-11-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-01-06
E · Potential for more than minimal harm
2021-11-19
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-01-06
E · Potential for more than minimal harm
2021-11-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-01-06
D · Potential for more than minimal harm
2021-11-19
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2022-01-06
D · Potential for more than minimal harm
2021-11-19
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2022-01-06
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-05-09
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 2025-05-30
D · Potential for more than minimal harm
2025-05-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-09
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 2025-05-30
D · Potential for more than minimal harm
2025-05-09
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-03
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-07
F585 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-03-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-28
D · Potential for more than minimal harm
2024-09-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-08-27
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-09-16
J · Immediate jeopardy
2024-08-03
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 2024-08-25
D · Potential for more than minimal harm
2024-08-03
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-08-03
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2024-08-25
D · Potential for more than minimal harm
2024-07-22
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-08-01
J · Immediate jeopardy
2024-05-06
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-05-29
J · Immediate jeopardy
2024-05-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-29
E · Potential for more than minimal harm
2024-05-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-05-29
E · Potential for more than minimal harm
2024-05-06
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 2024-05-29
E · Potential for more than minimal harm
2024-05-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-05-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-05-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-05-06
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-05-06
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 2024-05-29
D · Potential for more than minimal harm
2024-02-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-06
D · Potential for more than minimal harm
2023-11-16
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-12-05
E · Potential for more than minimal harm
2021-11-19
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2021-12-21
E · Potential for more than minimal harm
2021-11-19
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 2021-12-21
E · Potential for more than minimal harm
2021-11-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-21
D · Potential for more than minimal harm
2021-11-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-12-21
D · Potential for more than minimal harm
2021-11-19
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2021-12-21
D · Potential for more than minimal harm
2021-11-19
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 2021-12-21
D · Potential for more than minimal harm
2021-11-19
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 2021-12-21
D · Potential for more than minimal harm
2021-11-19
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2021-12-21
Penalties and ownership
What sits behind the stars
$15,536
2024-07-22
Fine
Fine · fine $15,536
Fine
$28,032
2024-05-06
Fine
Fine · fine $28,032
Fine
Ownership
College Vista LLC
5% Or Greater Direct Ownership Interest · Organization
Johnson, David
5% Or Greater Indirect Ownership Interest · Individual
Johnson, Frank
5% Or Greater Indirect Ownership Interest · Individual
Marmur, Eli
5% Or Greater Indirect Ownership Interest · Individual
Russakoff, Richard
5% Or Greater Indirect Ownership Interest · Individual
Arevalo, Armando
Operational/Managerial Control · Individual
Bassuk, Pablo
Operational/Managerial Control · Individual
College Vista LLC
Operational/Managerial Control · Organization
Dehghanmanesh, Adrian
Operational/Managerial Control · Individual
Dehghanmanesh, Adrian
Corporate Officer · Individual
Johnson, David
Operational/Managerial Control · Individual
Kochek, Joshua
Operational/Managerial Control · Individual
Oxford, Micheal
Operational/Managerial Control · Individual
Nearby options
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#2
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#3
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