Cycle 1
Health 2025-02-26 · Fire 2025-02-26
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Newbury Park, CA
Mary Health of the Sick Convalescent & Nursing Hos
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2929 Theresa Drive, Newbury Park, CA
(805) 498-3644
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
61
Certified beds
Average residents
55
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.95
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.82
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.54
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.94
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
0.00
Reported PT staffing
Adjusted RN hours
1.03
CMS adjusted RN staffing hours
Adjusted total hours
4.93
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
229
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
76.97
Composite VBP score used to determine payment impact.
Payment multiplier
1.0251
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 18.09% · Performance 16.77% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
4.64
Baseline 6.73% · Performance 6.45% · Measure score 4.64 · Achievement 4.64 · Improvement 1.15
Total nurse turnover
10
Baseline 30.44% · Performance 21.57% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
6.15
Baseline 5.40 hours · Performance 4.83 hours · Measure score 6.15 · Achievement 6.15 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.82% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 235 · Observed rate 8.51% · Lower 95% interval 7.95% |
| Discharge to community | 59.14% |
50.57%
8.6 pts better
|
Better than the National Rate · Eligible stays 257 · Observed rate 55.25% · Lower 95% interval 53.47% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.13% |
95.27%
3.9 pts better
|
Numerator 114 · Denominator 115 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 115 |
| Discharge self-care score | 52.69% |
53.69%
1 pts worse
|
Numerator 49 · Denominator 93 |
| Discharge mobility score | 77.42% |
50.94%
26.5 pts better
|
Numerator 72 · Denominator 93 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 115 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.45% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 141 · Observed rate 4.96% · Lower 95% interval 3.85% |
| Staff COVID-19 vaccination coverage | 13.04% |
8.2%
4.8 pts better
|
Numerator 15 · Denominator 115 |
| Staff flu vaccination coverage | 65.52% |
42%
23.5 pts better
|
Numerator 95 · Denominator 145 |
| Discharge function score | 77.42% |
56.45%
21 pts better
|
Numerator 72 · Denominator 93 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 76 · Denominator 76 |
| Resident COVID-19 vaccinations up to date | 35.19% |
25.2%
10 pts better
|
Numerator 19 · Denominator 54 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
2.3
1.2 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.7 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.6
1.3 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.2 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
98.5%
1.7 pts worse
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.0% · Q2 93.8% · Q3 100.0% · Q4 100.0% · 4Q avg 96.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.8% |
98.2%
4.4 pts worse
|
95.5%
1.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
1.6%
0.5 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · 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 | 1.8% |
4.1%
2.3 pts better
|
5.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.9% · Q3 2.3% · Q4 0.0% · 4Q avg 1.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.3% |
13.7%
1.4 pts better
|
19.6%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 14.9% · Q3 17.4% · Q4 7.0% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.1% |
14.2%
12.1 pts better
|
16.7%
14.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.9% · Q3 2.7% · Q4 0.0% · 4Q avg 2.1% · 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 | 9.5% |
11.0%
1.5 pts better
|
16.3%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 3.1% · Q3 18.4% · Q4 5.8% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.5% |
10.7%
0.8 pts worse
|
14.9%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 9.5% · Q3 15.9% · Q4 12.2% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.0%
0.4 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.5% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
1.2%
1.1 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 2.2% · Q4 4.4% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.0% |
10.9%
5.1 pts worse
|
19.8%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 22.2% · Q3 22.1% · Q4 8.0% · 4Q avg 16.0% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
4.7%
2.4 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 2.6% · Q4 2.7% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
94.0%
2.3 pts better
|
81.7%
14.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.0% · Q3 93.8% · Q4 93.6% · 4Q avg 96.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 1.4% |
11.2%
9.8 pts better
|
12.0%
10.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 1.4% · Observed 1.2% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 67.9% |
93.2%
25.3 pts worse
|
79.7%
11.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 67.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 7.9% |
23.2%
15.3 pts better
|
23.9%
16 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 7.0% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-10 · Fire 2023-02-10
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2019-10-10 · Fire 2019-10-10
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-02-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-26
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-03-27
E · Potential for more than minimal harm
2023-02-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-14
D · Potential for more than minimal harm
2023-02-10
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-03-14
D · Potential for more than minimal harm
2023-02-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-14
D · Potential for more than minimal harm
2023-02-10
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-14
D · Potential for more than minimal harm
2023-02-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-14
C · Minimal harm
2023-02-10
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-03-14
D · Potential for more than minimal harm
2019-10-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-05
D · Potential for more than minimal harm
2019-10-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-12-05
D · Potential for more than minimal harm
2019-10-10
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2019-12-05
D · Potential for more than minimal harm
2019-10-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-12-05
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-26
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 2025-03-22
F · Potential for more than minimal harm
2023-02-10
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 2023-03-16
F · Potential for more than minimal harm
2023-02-10
F838 · Administration Deficiencies
Health
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.
Corrected 2023-03-16
F · Potential for more than minimal harm
2023-02-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-16
D · Potential for more than minimal harm
2023-02-10
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 2023-03-16
D · Potential for more than minimal harm
2023-02-10
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 2023-03-16
D · Potential for more than minimal harm
2023-02-10
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 2023-03-16
D · Potential for more than minimal harm
2023-02-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-03-16
D · Potential for more than minimal harm
2023-02-10
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 2023-03-16
E · Potential for more than minimal harm
2019-10-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-11-08
D · Potential for more than minimal harm
2019-10-10
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 2019-10-10
D · Potential for more than minimal harm
2019-10-10
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 2019-11-08
Penalties and ownership
What sits behind the stars
Ownership
Afshar, Shideh
W-2 Managing Employee · Individual
Garcia Valencia, Lucero
Corporate Officer · Individual
Lara, Lourdes
Corporate Director · Individual
Lara, Lourdes
Corporate Officer · Individual
Perea, Yesenia
Corporate Director · Individual
Perea, Yesenia
Corporate Officer · Individual
Rodriguez, Carmen
Corporate Director · Individual
Rodriguez, Carmen
Corporate Officer · Individual
Schmidt, Betty
W-2 Managing Employee · Individual
Servants Of Mary Ministers To The Sick Inc
5% Or Greater Direct Ownership Interest · Organization
Zamora, Claudia
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Alta Healthcare Center of Camarillo
Camarillo, CA
4-star overall rating with 4-star inspections with $43,407 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Thousand Oaks Post Acute, LLC
Thousand Oaks, CA
3-star overall rating with 3-star inspections with $20,703 in total fines with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Oakview Skilled Nursing
Thousand Oaks, CA
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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