Federal inspection record · CMS data as of October 1, 2026
Colonial Gardens Nursing Home
7246 S. Rosemead Blvd., Pico Rivera, CA · (562) 949-2591
- Certified beds
- 99
- Residents per day
- 93
- Ownership
- For-Profit
- Chain
- No chain reported
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- December 3, 1997
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in California.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change (already 1)
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among California homes
Colonial Gardens Nursing Home carries 202.75 inspection points. That is fewer than 9% of California's 1,154 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in California: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–33 pts
- 4★ 33–66 pts
- 3★ 66–96 pts
- 2★ 96–146 pts
- 1★ over 146 pts
Bars show every rated home in California by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
108 health citations on record since 2022. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (2)
-
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
G
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Everything else, by area of care
Resident Assessment and Care Planning22E
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Ensure each resident receives an accurate assessment.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Assess the resident when there is a significant change in condition
- D
Ensure each resident receives an accurate assessment.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure each resident receives an accurate assessment.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure each resident receives an accurate assessment.
Resident Rights16E
- D
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
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- D
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.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- E
Ensure that residents are fully informed and understand their health status, care and treatments.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- E
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
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Quality of Life and Care16E
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
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
Provide safe and appropriate respiratory care for a resident when needed.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide enough food/fluids to maintain a resident's health.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Freedom from Abuse, Neglect, and Exploitation12F
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
- F
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- E
Respond appropriately to all alleged violations.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Pharmacy Service12F
- D
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.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- F
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.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- E
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.
- E
Ensure medication error rates are not 5 percent or greater.
- E
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.
- D
Ensure that residents are free from significant medication errors.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
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.
- E
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.
Environmental7E
- E
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
- B
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- E
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
- B
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- D
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
- B
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Infection Control7F
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- F
Provide and implement an infection prevention and control program.
- F
Implement a program that monitors antibiotic use.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- E
Provide and implement an infection prevention and control program.
Nutrition and Dietary6F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
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.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- F
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.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Administration5F
- D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- F
Have a plan that describes the process for conducting QAPI and QAA activities.
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Nursing and Physician Services3E
- D
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.
- E
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.
- B
Post nurse staffing information every day.
Inspection history
2025-05-22
33 health deficiencies · 5 fire-safety deficiencies
Top issue: Resident Assessment and Care Planning (11 deficiencies)
2024-06-27
44 health deficiencies · 4 fire-safety deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
2022-04-08
31 health deficiencies · 8 fire-safety deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 15 min of nursing staff time a day, 28 min of it from a registered nurse.
This home
4 h 15 min
California average
4 h 33 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 37% of nursing staff and 42% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$36,700 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2024-08-05 | Fine | $36,700 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days2.6 pts worse | 4.8 | 2.2 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.2 pts worse | 1.7 | 1.5 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine1.3 pts better | 100.0% | 98.7% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine2.1 pts better | 100.0% | 97.9% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.1 pts better | 1.5% | 1.6% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms78.4 pts worse | 86.0% | 7.6% | 13.5% |
| Percentage of long-stay residents who lose too much weight0.4 pts worse | 4.5% | 4.1% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication3.1 pts better | 10.6% | 13.7% | 19.5% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.3% | 0.3% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened2 pts better | 6.9% | 8.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased10 pts worse | 20.2% | 10.2% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.5 pts better | 0.2% | 0.7% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection1.2 pts better | 0.0% | 1.2% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence5.2 pts better | 4.6% | 9.8% | 18.3% |
| Percentage of long-stay residents with pressure ulcersAbout the same | 4.3% | 4.3% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine5.4 pts better | 100.0% | 94.6% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit4.1 pts better | 7.0% | 11.1% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication29.1 pts worse | 30.4% | 1.3% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine6.9 pts better | 100.0% | 93.1% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission5.2 pts worse | 27.8% | 22.6% | 23.4% |
·
Who owns and runs it
13 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Lehmann, Kenneth | 5% Or Greater Direct Ownership Interest · Individual | 25% | 17 facilities |
| Ahm Trust | 5% Or Greater Direct Ownership Interest · Organization | 20% | 6 facilities |
| Abe And Rachel Bak Family Trust | Adp Of The SNF · Organization | 0% | 10 facilities |
| Bak, Abraham | Corporate Officer · Individual | 0% | 24 facilities |
| Bak, Abraham | Adp Of The SNF · Individual | 0% | 24 facilities |
| Gastwirth, Menachem | Corporate Officer · Individual | 0% | 21 facilities |
| Gastwirth, Menachem | Adp Of The SNF · Individual | 0% | 21 facilities |
| Lehmann, Kenneth | Adp Of The SNF · Individual | 0% | 17 facilities |
| Stephens, Kent | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Stephens, Kent | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Stephens, Kent | Adp Of The SNF · Individual | 0% | 1 facilities |
| Victoria, Xanthe | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Victoria, Xanthe | Adp Of The SNF · Individual | 0% | 1 facilities |
·
Fire safety
17 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke7F
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- D
Inspect, test, and maintain automatic sprinkler systems.
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Install an approved automatic sprinkler system.
- E
Inspect, test, and maintain automatic sprinkler systems.
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Miscellaneous4F
- C
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- E
Have simulated fire drills held at unexpected times.
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Gas, Vacuum, and Electrical Systems3E
- E
Ensure proper usage of power strips and extension cords.
- D
Meet requirements for the installation and maintenance of electrical systems.
- D
Ensure proper usage of power strips and extension cords.
Emergency Preparedness2E
- C
Establish policies and procedures for medical documentation.
- E
Provide emergency officials' contact information.
Services1D
- D
Have properly installed electrical wiring and gas equipment.
·
Other homes nearby
-
El Rancho Vista Health Care Center
Pico Rivera, CA
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 4 h 31 min
- Fines
- $0
-
Riviera Healthcare Center
Pico Rivera, CA
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 4 h 5 min
- Fines
- $9,110
-
Brookfield Healthcare Center
Downey, CA · The Ensign Group
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 4 h 5 min
- Fines
- $0