Cycle 1
Health 2025-03-30 · Fire 2025-03-30
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Van Nuys, CA
Lake Balboa Care Center
5-star overall rating with 5-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
16955 Vanowen Street, Van Nuys, CA
(818) 343-0700
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
50
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1972-05-01
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
Hours and turnover
RN hours / resident day
0.78
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.37
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
4.65
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.16
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.98
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.28
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
3.25
CMS adjusted total nurse staffing hours
Case-mix index
1.95
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,479
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9872
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.28
Baseline 19.47% · Performance 19.45% · Measure score 4.28 · Achievement 4.28 · Improvement 0
Healthcare-associated infections
0
Baseline 9.31% · Performance 9.09% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.43
Baseline 68.35% · Performance 33.85% · Measure score 7.43 · Achievement 7.30 · Improvement 7.43
Adjusted total nurse staffing
1.36
Baseline 4.44 hours · Performance 3.47 hours · Measure score 1.36 · Achievement 1.36 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.68% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 534 · Observed rate 11.61% · Lower 95% interval 9.67% |
| Discharge to community | 60.27% |
50.57%
9.7 pts better
|
Better than the National Rate · Eligible stays 614 · Observed rate 54.07% · Lower 95% interval 55.74% |
| Medicare spending per beneficiary | 1.31 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 430 · Denominator 430 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 430 |
| Discharge self-care score | 75.25% |
53.69%
21.6 pts better
|
Numerator 225 · Denominator 299 |
| Discharge mobility score | 73.58% |
50.94%
22.6 pts better
|
Numerator 220 · Denominator 299 |
| Pressure ulcers or injuries, new or worsened | 0.93% |
2.29%
1.4 pts better
|
Numerator 4 · Denominator 430 · Adjusted rate 0.84% |
| Healthcare-associated infections requiring hospitalization | 9.09% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 424 · Observed rate 9.91% · Lower 95% interval 6.78% |
| Staff COVID-19 vaccination coverage | 15% |
8.2%
6.8 pts better
|
Numerator 18 · Denominator 120 |
| Staff flu vaccination coverage | 28.57% |
42%
13.4 pts worse
|
Numerator 40 · Denominator 140 |
| Discharge function score | 76.59% |
56.45%
20.1 pts better
|
Numerator 229 · Denominator 299 |
| Transfer of health information to provider | 99.48% |
95.95%
3.5 pts better
|
Numerator 190 · Denominator 191 |
| Transfer of health information to patient | 94.35% |
96.28%
1.9 pts worse
|
Numerator 217 · Denominator 230 |
| Resident COVID-19 vaccinations up to date | 9.91% |
25.2%
15.3 pts worse
|
Numerator 22 · Denominator 222 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
94.0%
5.7 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.6% · Q3 99.3% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
11.2%
4.5 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 6.6% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.6% · Q3 0.6% · Q4 0.6% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.3% |
93.2%
5.1 pts better
|
79.7%
18.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| 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 25.8% · Expected 26.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-21 · Fire 2024-03-21
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-11-21 · Fire 2021-11-21
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-11
E · Potential for more than minimal harm
2024-03-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-04-11
E · Potential for more than minimal harm
2024-03-21
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-21
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-04-11
F · Potential for more than minimal harm
2021-11-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2021-12-10
E · Potential for more than minimal harm
2021-11-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-12-10
D · Potential for more than minimal harm
2021-11-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-12-10
D · Potential for more than minimal harm
2021-11-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-12-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-26
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2026-02-11
D · Potential for more than minimal harm
2025-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-18
D · Potential for more than minimal harm
2025-03-30
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 2025-04-08
D · Potential for more than minimal harm
2025-03-30
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-04-08
D · Potential for more than minimal harm
2025-03-30
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-08
D · Potential for more than minimal harm
2025-03-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-08
B · Minimal harm
2025-03-30
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2025-04-08
D · Potential for more than minimal harm
2024-12-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-12-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-21
E · Potential for more than minimal harm
2024-03-21
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 2024-04-10
D · Potential for more than minimal harm
2024-03-21
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 2024-04-10
D · Potential for more than minimal harm
2024-03-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-03-21
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 2024-04-10
D · Potential for more than minimal harm
2024-03-21
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 2024-04-10
B · Minimal harm
2024-03-21
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2024-04-10
D · Potential for more than minimal harm
2023-05-25
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 2023-06-09
E · Potential for more than minimal harm
2021-11-21
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2021-12-20
E · Potential for more than minimal harm
2021-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-20
D · Potential for more than minimal harm
2021-11-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-12-20
D · Potential for more than minimal harm
2021-11-21
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 2021-12-20
D · Potential for more than minimal harm
2021-11-21
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 2021-12-20
D · Potential for more than minimal harm
2021-11-21
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 2021-12-20
B · Minimal harm
2021-11-21
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Not marked corrected
Penalties and ownership
What sits behind the stars
Ownership
Flagstone Healthcare South LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Barron, Craig
Operational/Managerial Control · Individual
Burnam, Soon
Corporate Officer · Individual
Gamero, Alicia
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Sato, Ami
Corporate Officer · Individual
Shirazi, Keyvan
Operational/Managerial Control · Individual
Willits, Adam
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
California Healthcare And Rehabilitation Center
Van Nuys, CA
1-star overall rating with 1-star inspections with $20,102 in total fines with 37 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Berkley Post-Acute
Van Nuys, CA
3-star overall rating with 2-star inspections with 14 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Terrace Post Acute
Van Nuys, CA
1-star overall rating with 1-star inspections with $94,094 in total fines with 21 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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