Cycle 1
Health 2025-02-16 · Fire 2025-02-16
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Baldwin Park, CA
Victoria Care Center
5-star overall rating with 4-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3541 Puente Avenue, Baldwin Park, CA
(626) 962-1043
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
49
Certified beds
Average residents
44
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
David & Frank Johnson
Operator or chain grouping
Approved since
1979-02-05
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
0.34
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.41
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.55
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.31
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.91
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
3.80
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
40%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,583
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.37
Composite VBP score used to determine payment impact.
Payment multiplier
0.9854
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
3.06
Baseline 11.36% · Performance 9.09% · Measure score 3.06 · Achievement 0 · Improvement 3.06
Total nurse turnover
3.35
Baseline 51.72% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0.14
Adjusted total nurse staffing
2.4
Baseline 4.47 hours · Performance 3.76 hours · Measure score 2.4 · Achievement 2.4 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.7% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 50 · Observed rate 12% · Lower 95% interval 6.73% |
| Discharge to community | 43.37% |
50.57%
7.2 pts worse
|
No Different than the National Rate · Eligible stays 34 · Observed rate 32.35% · Lower 95% interval 31.39% |
| Medicare spending per beneficiary | 1.44 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 75 · Denominator 75 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 75 |
| Discharge self-care score | 64.71% |
53.69%
11 pts better
|
Numerator 22 · Denominator 34 |
| Discharge mobility score | 55.88% |
50.94%
4.9 pts better
|
Numerator 19 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 1.33% |
2.29%
1 pts better
|
Numerator 1 · Denominator 75 · Adjusted rate 0.75% |
| Healthcare-associated infections requiring hospitalization | 9.09% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 16.22% · Lower 95% interval 5.6% |
| Staff COVID-19 vaccination coverage | 14.29% |
8.2%
6.1 pts better
|
Numerator 12 · Denominator 84 |
| Staff flu vaccination coverage | 60.92% |
42%
18.9 pts better
|
Numerator 53 · Denominator 87 |
| Discharge function score | 61.76% |
56.45%
5.3 pts better
|
Numerator 21 · Denominator 34 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 38 · Denominator 38 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 28.95% |
25.2%
3.8 pts better
|
Numerator 11 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.4 |
2.3
1.1 pts worse
|
1.9
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 6.2 · Expected 3.4 · 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 1.7 · Expected 2.3 · 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 | 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 | 1.5% |
1.6%
0.1 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 20.4% |
6.8%
13.6 pts worse
|
11.4%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.6% · Q2 20.7% · Q3 19.4% · Q4 3.1% · 4Q avg 20.4% |
| Percentage of long-stay residents who lose too much weight | 0.8% |
4.1%
3.3 pts better
|
5.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.2% |
13.7%
4.5 pts better
|
19.6%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 12.5% · Q3 8.3% · Q4 2.7% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.4% |
14.2%
10.8 pts better
|
16.7%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 0.0% · Q3 8.7% · Q4 0.0% · 4Q avg 3.4% · 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 | 3.5% |
11.0%
7.5 pts better
|
16.3%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.6% |
10.7%
0.1 pts better
|
14.9%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 19.2% · Q3 7.1% · Q4 6.2% · 4Q avg 10.6% · 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 · 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 | 10.4% |
10.9%
0.5 pts better
|
19.8%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 14.7% · Q3 3.3% · Q4 5.4% · 4Q avg 10.4% |
| Percentage of long-stay residents with pressure ulcers | 9.4% |
4.7%
4.7 pts worse
|
5.1%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 17.4% · Q3 10.1% · Q4 5.8% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
94.0%
5.1 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.1% · Q4 97.8% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 1.8% |
11.2%
9.4 pts better
|
12.0%
10.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 1.8% · Observed 2.1% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.2%
6.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.1% |
23.2%
4.9 pts worse
|
23.9%
4.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.1% · Observed 33.3% · Expected 28.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-11 · Fire 2024-02-11
15 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2021-10-28 · Fire 2021-10-28
16 health deficiencies
Top issue: Resident Rights (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-02-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-12
D · Potential for more than minimal harm
2024-02-11
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 2024-02-29
F · Potential for more than minimal harm
2021-10-28
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-12-01
F · Potential for more than minimal harm
2021-10-28
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2021-12-01
F · Potential for more than minimal harm
2021-10-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-12-01
E · Potential for more than minimal harm
2021-10-28
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 2021-12-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-16
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 2025-06-04
E · Potential for more than minimal harm
2025-02-16
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 2025-02-26
E · Potential for more than minimal harm
2025-02-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-18
E · Potential for more than minimal harm
2025-02-16
F700 · Quality of Life and Care Deficiencies
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 2025-02-18
E · Potential for more than minimal harm
2025-02-16
F758 · Pharmacy Service Deficiencies
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 2025-02-17
E · Potential for more than minimal harm
2025-02-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-02-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-19
D · Potential for more than minimal harm
2025-02-16
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-02-17
B · Minimal harm
2025-02-16
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 2025-02-17
D · Potential for more than minimal harm
2024-11-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-06-13
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-07-02
E · Potential for more than minimal harm
2024-02-11
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 2024-02-29
E · Potential for more than minimal harm
2024-02-11
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-02-11
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 2024-02-29
D · Potential for more than minimal harm
2024-02-11
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 2024-02-29
D · Potential for more than minimal harm
2024-02-11
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 2024-02-29
D · Potential for more than minimal harm
2024-02-11
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-02-11
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 2024-02-29
D · Potential for more than minimal harm
2024-02-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-02-11
F726 · Nursing and Physician Services Deficiencies
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 2024-02-29
D · Potential for more than minimal harm
2024-02-11
F756 · Pharmacy Service Deficiencies
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 2024-02-29
D · Potential for more than minimal harm
2024-02-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-02-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-29
B · Minimal harm
2024-02-11
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 2024-02-29
D · Potential for more than minimal harm
2024-01-09
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-07-21
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-07-14
F700 · Quality of Life and Care Deficiencies
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 2023-08-09
D · Potential for more than minimal harm
2023-06-13
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2023-06-19
G · Actual harm
2021-10-28
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-01-12
G · Actual harm
2021-10-28
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 2022-01-12
E · Potential for more than minimal harm
2021-10-28
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 2022-01-12
D · Potential for more than minimal harm
2021-10-28
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 2022-01-12
D · Potential for more than minimal harm
2021-10-28
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 2022-01-12
D · Potential for more than minimal harm
2021-10-28
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-01-12
D · Potential for more than minimal harm
2021-10-28
F642 · Resident Assessment and Care Planning Deficiencies
Health
Ensure a qualified health professional conducts resident assessments.
Corrected 2022-01-12
D · Potential for more than minimal harm
2021-10-28
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-01-12
D · Potential for more than minimal harm
2021-10-28
F756 · Pharmacy Service Deficiencies
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 2022-01-12
D · Potential for more than minimal harm
2021-10-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-01-12
C · Minimal harm
2021-10-28
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-01-12
B · Minimal harm
2021-10-28
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 2022-01-12
Penalties and ownership
What sits behind the stars
Ownership
Bauman, Irving
5% Or Greater Direct Ownership Interest · Individual
Johnson, Frank
5% Or Greater Direct Ownership Interest · Individual
Dehghanmanesh, Adrian
Operational/Managerial Control · Individual
Dehghanmanesh, Adrian
Corporate Officer · Individual
Johnson, Frank
Corporate Officer · Individual
Kaur, Ragini
W-2 Managing Employee · Individual
Kochek, Joshua
Operational/Managerial Control · Individual
Oxford, Micheal
Operational/Managerial Control · Individual
Puente Partners LLC
Operational/Managerial Control · Organization
Sun Mar Management Services
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
West Covina Healthcare Center
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
#2
West Covina Medical Center D/P SNF
West Covina, CA
3-star overall rating with 4-star inspections with $7,026 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Garden View Post Acute Rehabilitation
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
Jump out