Cycle 1
Health 2025-12-17 · Fire 2025-12-17
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Rosemead, CA
Del Mar Convalescent Hospital
5-star overall rating with 4-star inspections with 10 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
3136 North Del Mar Avenue, Rosemead, CA
(626) 288-8353
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
59
Certified beds
Average residents
57
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
David & Frank Johnson
Operator or chain grouping
Approved since
1978-02-13
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
0.63
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.59
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
1.51
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.77
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.44
CMS adjusted total nurse staffing hours
Case-mix index
1.63
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,874
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9865
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.59
Baseline 24.23% · Performance 22.73% · Measure score 1.59 · Achievement 0 · Improvement 1.59
Healthcare-associated infections
0
Baseline 8.21% · Performance 9.04% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
9.35
Baseline 37.10% · Performance 25.45% · Measure score 9.35 · Achievement 9.35 · Improvement 9
Adjusted total nurse staffing
1.65
Baseline 3.75 hours · Performance 3.55 hours · Measure score 1.65 · Achievement 1.65 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.41% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 122 · Observed rate 9.84% · Lower 95% interval 6.62% |
| Discharge to community | 39.45% |
50.57%
11.1 pts worse
|
Worse than the National Rate · Eligible stays 138 · Observed rate 30.43% · Lower 95% interval 27.77% |
| Medicare spending per beneficiary | 1.76 |
1.02
0.7 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 160 · Denominator 160 |
| Falls with major injury | 1.88% |
0.77%
1.1 pts worse
|
Numerator 3 · Denominator 160 |
| Discharge self-care score | 71.29% |
53.69%
17.6 pts better
|
Numerator 72 · Denominator 101 |
| Discharge mobility score | 69.31% |
50.94%
18.4 pts better
|
Numerator 70 · Denominator 101 |
| Pressure ulcers or injuries, new or worsened | 0.63% |
2.29%
1.7 pts better
|
Numerator 1 · Denominator 160 · Adjusted rate 0.35% |
| Healthcare-associated infections requiring hospitalization | 9.04% |
7.12%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 111 · Observed rate 12.61% · Lower 95% interval 5.57% |
| Staff COVID-19 vaccination coverage | 24.44% |
8.2%
16.2 pts better
|
Numerator 22 · Denominator 90 |
| Staff flu vaccination coverage | 66.67% |
42%
24.7 pts better
|
Numerator 60 · Denominator 90 |
| Discharge function score | 70.3% |
56.45%
13.8 pts better
|
Numerator 71 · Denominator 101 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 95 · Denominator 95 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 29.11% |
25.2%
3.9 pts better
|
Numerator 23 · Denominator 79 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.3
0.7 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.8 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.6
1.1 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.3 · 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 | 98.1% |
98.2%
0.1 pts worse
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 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 who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 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 lose too much weight | 2.0% |
4.1%
2.1 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 0.0% · Q3 2.8% · Q4 0.0% · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 1.3% |
13.7%
12.4 pts better
|
19.6%
18.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.7% |
14.2%
12.5 pts better
|
16.7%
15 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 7.4% · 4Q avg 1.7% · 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 | 1.5% |
11.0%
9.5 pts better
|
16.3%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.7% |
10.7%
9 pts better
|
14.9%
13.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · 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 | 0.7% |
10.9%
10.2 pts better
|
19.8%
19.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
4.7%
3.2 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
94.0%
5.3 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.6% · Q3 98.9% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.1% |
11.2%
6.1 pts better
|
12.0%
6.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.1% · Observed 4.8% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.3% |
93.2%
4.1 pts better
|
79.7%
17.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.5% |
23.2%
1.3 pts worse
|
23.9%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.5% · Observed 24.2% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-10 · Fire 2024-11-10
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-11-12 · Fire 2023-11-12
10 health deficiencies
Top issue: Resident Rights (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-12
F · Potential for more than minimal harm
2025-12-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-12
F · Potential for more than minimal harm
2025-12-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-12-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-12-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-12-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-12-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2026-01-12
C · Minimal harm
2025-12-17
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2026-01-12
C · Minimal harm
2025-12-17
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2026-01-12
F · Potential for more than minimal harm
2024-11-10
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-11-10
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-11-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-03
F · Potential for more than minimal harm
2023-11-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-12
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-12
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 2023-12-15
E · Potential for more than minimal harm
2023-11-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-12
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-12
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 2023-12-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-17
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 2026-01-12
E · Potential for more than minimal harm
2025-12-17
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 2026-01-12
E · Potential for more than minimal harm
2025-12-17
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 2026-01-12
E · Potential for more than minimal harm
2025-12-17
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-12-17
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 2026-01-06
D · Potential for more than minimal harm
2025-12-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-12-17
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 2026-01-12
D · Potential for more than minimal harm
2025-12-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-12-17
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2026-01-12
B · Minimal harm
2025-12-17
F911 · Environmental Deficiencies
Health
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Corrected 2026-01-12
E · Potential for more than minimal harm
2024-11-10
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 2024-12-04
E · Potential for more than minimal harm
2024-11-10
F911 · Environmental Deficiencies
Health
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Corrected 2024-12-04
D · Potential for more than minimal harm
2024-11-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-04
D · Potential for more than minimal harm
2024-11-10
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 2024-12-04
D · Potential for more than minimal harm
2024-11-10
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-12-04
D · Potential for more than minimal harm
2024-11-10
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 2024-12-04
D · Potential for more than minimal harm
2024-11-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-04
D · Potential for more than minimal harm
2023-11-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-12-12
D · Potential for more than minimal harm
2023-11-12
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-12-12
D · Potential for more than minimal harm
2023-11-12
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-12-12
D · Potential for more than minimal harm
2023-11-12
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 2023-12-12
D · Potential for more than minimal harm
2023-11-12
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-12-12
D · Potential for more than minimal harm
2023-11-12
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 2023-12-12
D · Potential for more than minimal harm
2023-11-12
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2023-12-12
D · Potential for more than minimal harm
2023-11-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-12
B · Minimal harm
2023-11-12
F911 · Environmental Deficiencies
Health
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Corrected 2023-12-12
D · Potential for more than minimal harm
2023-06-26
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 2023-07-11
Penalties and ownership
What sits behind the stars
Ownership
Gibraltar Convalescent Hospital Inc
5% Or Greater Direct Ownership Interest · Organization
Johnson, Frank
5% Or Greater Indirect Ownership Interest · Individual
Marmur, Eli
5% Or Greater Indirect Ownership Interest · Individual
Clayton, Craig
Operational/Managerial Control · Individual
Dehghanmanesh, Adrian
Operational/Managerial Control · Individual
Dehghanmanesh, Adrian
Corporate Officer · Individual
Farrales, Mary
Operational/Managerial Control · Individual
Farrales, Mary
Corporate Officer · Individual
Gibraltar Convalescent Hospital Inc
Operational/Managerial Control · Organization
Johnson, Frank
Operational/Managerial Control · Individual
Johnson, Frank
Corporate Director · Individual
Kochek, Joshua
Operational/Managerial Control · Individual
Kochek, Joshua
Corporate Officer · Individual
Oxford, Micheal
Operational/Managerial Control · Individual
Oxford, Micheal
Corporate Officer · Individual
Tran, Dan
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Monterey Park Conv Hosp
Monterey Park, CA
4-star overall rating with 3-star inspections with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Heritage Manor
Monterey Park, CA
2-star overall rating with 1-star inspections with $17,940 in total fines with 19 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
San Gabriel Conv Center
Rosemead, CA
2-star overall rating with 2-star inspections with 20 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Jump out