12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Baldwin Park, CA
4-star overall rating with 3-star inspections with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
14475 Garden View Lane, Baldwin Park, CA
(626) 962-7095
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
97
Certified beds
Average residents
89
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1972-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 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
RN hours / resident day
0.44
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.15
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.56
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.14
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.73
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.65
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
9,697
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9830
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 21.88% · Performance 22.19% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.18
Baseline 10.98% · Performance 10.58% · Measure score 0.18 · Achievement 0 · Improvement 0.18
Total nurse turnover
6.23
Baseline 27.54% · Performance 38.20% · Measure score 6.23 · Achievement 6.23 · Improvement 0
Adjusted total nurse staffing
2.72
Baseline 3.48 hours · Performance 3.85 hours · Measure score 2.72 · Achievement 2.72 · Improvement 1.12
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.12% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 237 · Observed rate 11.39% · Lower 95% interval 7.97% |
| Discharge to community | 56.93% |
50.57%
6.4 pts better
|
No Different than the National Rate · Eligible stays 261 · Observed rate 47.89% · Lower 95% interval 49.87% |
| Medicare spending per beneficiary | 1.45 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 197 · Denominator 197 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 197 |
| Discharge self-care score | 64.86% |
53.69%
11.2 pts better
|
Numerator 48 · Denominator 74 |
| Discharge mobility score | 58.11% |
50.94%
7.2 pts better
|
Numerator 43 · Denominator 74 |
| Pressure ulcers or injuries, new or worsened | 3.05% |
2.29%
0.8 pts worse
|
Numerator 6 · Denominator 197 · Adjusted rate 1.91% |
| Healthcare-associated infections requiring hospitalization | 10.58% |
7.12%
3.5 pts worse
|
Worse than the National Rate · Eligible stays 210 · Observed rate 14.29% · Lower 95% interval 7.37% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 148 |
| Staff flu vaccination coverage | 41.62% |
42%
0.4 pts worse
|
Numerator 72 · Denominator 173 |
| Discharge function score | 68.92% |
56.45%
12.5 pts better
|
Numerator 51 · Denominator 74 |
| Transfer of health information to provider | 98.92% |
95.95%
3 pts better
|
Numerator 92 · Denominator 93 |
| Transfer of health information to patient | 98.33% |
96.28%
2 pts better
|
Numerator 59 · Denominator 60 |
| Resident COVID-19 vaccinations up to date | 23.86% |
25.2%
1.3 pts worse
|
Numerator 21 · Denominator 88 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
2.3
0.5 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 3.8 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.6
0.4 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.8 · 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 | 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 | 3.5% |
6.8%
3.3 pts better
|
11.4%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.8% · Q3 5.1% · Q4 1.6% · 4Q avg 3.5% |
| Percentage of long-stay residents who lose too much weight | 6.6% |
4.1%
2.5 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 7.0% · Q3 4.8% · Q4 9.5% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.2% |
13.7%
0.5 pts better
|
19.6%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 11.3% · Q3 13.6% · Q4 13.2% · 4Q avg 13.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.8% |
14.2%
9.4 pts better
|
16.7%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 5.6% · Q3 2.3% · Q4 4.4% · 4Q avg 4.8% · 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 | 7.7% |
11.0%
3.3 pts better
|
16.3%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.3% |
10.7%
1.6 pts worse
|
14.9%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 14.9% · Q3 15.1% · Q4 15.8% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.4% |
1.0%
2.4 pts worse
|
1.0%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.6% · Q3 5.1% · Q4 4.9% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.2%
0.4 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.2% |
10.9%
7.3 pts worse
|
19.8%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 27.2% · Q3 15.4% · Q4 14.1% · 4Q avg 18.2% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
4.7%
0.2 pts worse
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 6.0% · Q3 3.8% · Q4 3.3% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
94.0%
5.8 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.2% |
11.2%
7 pts better
|
12.0%
7.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.2% · Observed 4.5% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.5%
1 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.1% · Q4 5.4% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.7% |
93.2%
13.5 pts worse
|
79.7%
About the same
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.2% |
23.2%
3 pts better
|
23.9%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 23.4% · Expected 27.7% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
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 2025-01-14
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-01-08
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-08
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-01-14
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-01-14
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-01-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-15
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-08-18
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2021-08-18
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2021-08-18
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2021-08-18
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 2021-08-18
Fire Safety
Construct fire resistant interior walls.
Corrected 2021-08-18
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2021-08-18
Inspection history
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-15
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-15
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 2025-02-15
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-02-15
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-15
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-02-15
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-15
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-15
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 2025-02-15
Health
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.
Corrected 2025-02-15
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-02-15
Health
Post nurse staffing information every day.
Corrected 2025-02-15
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-20
Health
Provide appropriate foot care.
Corrected 2024-12-20
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 2024-01-30
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-30
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-30
Health
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.
Corrected 2024-01-30
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-30
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-30
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-30
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-01-30
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-01-30
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 2024-01-30
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-30
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2024-01-11
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-15
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 2021-07-21
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-21
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-07-21
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-07-21
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-07-21
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 2021-07-21
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2021-07-21
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-07-21
Health
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.
Corrected 2021-07-21
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2021-07-21
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Nearby options
West Covina, CA
3-star overall rating with 3-star inspections with $86,320 in total fines with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Baldwin Park, CA
5-star overall rating with 4-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
West Covina, CA
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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