Cycle 1
Health 2024-10-25 · Fire 2024-10-25
16 health deficiencies
Top issue: Resident Rights (5 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
North Hollywood, CA
Vineland Post Acute
3-star overall rating with 3-star inspections with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
10830 Oxnard Street, North Hollywood, CA
(818) 763-8247
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
49
Certified beds
Average residents
45
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
David & Frank Johnson
Operator or chain grouping
Approved since
1976-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.37
Registered nurse staffing
LPN hours / resident day
1.58
Licensed practical nurse staffing
Aide hours / resident day
2.67
Nurse aide staffing
Weekend hours
3.93
Weekend nurse staffing
RN turnover
40%
Annual RN turnover
Total nurse turnover
21%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
2.3
0.8 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.6
0.4 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 |
| 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 |
| 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 |
| 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 |
| Percentage of long-stay residents who have depressive symptoms | 18.0% |
6.8%
11.2 pts worse
|
11.4%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.4% |
4.1%
0.7 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.0% |
13.7%
4.3 pts worse
|
19.6%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 19.8% |
14.2%
5.6 pts worse
|
16.7%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.8% |
11.0%
4.2 pts better
|
16.3%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.9% |
10.7%
1.8 pts better
|
14.9%
6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.3% |
10.9%
5.6 pts better
|
19.8%
14.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
4.7%
0.7 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.3% |
11.2%
4.1 pts worse
|
12.0%
3.3 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.6% |
93.2%
4.4 pts better
|
79.7%
17.9 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.5% |
23.2%
7.3 pts worse
|
23.9%
6.6 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-12 · Fire 2023-11-12
23 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-12-09 · Fire 2021-12-09
10 health deficiencies
Top issue: Environmental (2 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-15
F · Potential for more than minimal harm
2023-11-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-12-07
E · Potential for more than minimal harm
2023-11-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-07
E · Potential for more than minimal harm
2023-11-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-07
D · Potential for more than minimal harm
2023-11-12
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-12-07
F · Potential for more than minimal harm
2021-12-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-01-11
F · Potential for more than minimal harm
2021-12-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-01-11
F · Potential for more than minimal harm
2021-12-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-09
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-09
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-09
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 2022-01-11
C · Minimal harm
2021-12-09
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-01-11
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-01-14
D · Potential for more than minimal harm
2025-12-22
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-01-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-15
E · Potential for more than minimal harm
2024-12-19
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 2025-01-06
D · Potential for more than minimal harm
2024-12-02
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-23
E · Potential for more than minimal harm
2024-10-25
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 2024-11-15
E · Potential for more than minimal harm
2024-10-25
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 2024-11-15
E · Potential for more than minimal harm
2024-10-25
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 2024-11-15
E · Potential for more than minimal harm
2024-10-25
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-25
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-25
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-25
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 2024-11-15
D · Potential for more than minimal harm
2024-10-25
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-25
F690 · Quality of Life and Care Deficiencies
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 2024-11-15
D · Potential for more than minimal harm
2024-10-25
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-25
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 2024-11-15
D · Potential for more than minimal harm
2024-10-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-15
B · Minimal harm
2024-10-25
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-11-15
B · Minimal harm
2024-10-25
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 2024-11-15
F · Potential for more than minimal harm
2023-11-12
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-12-07
F · Potential for more than minimal harm
2023-11-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-07
E · Potential for more than minimal harm
2023-11-12
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 2023-12-07
E · Potential for more than minimal harm
2023-11-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-07
E · Potential for more than minimal harm
2023-11-12
F690 · Quality of Life and Care Deficiencies
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 2023-12-07
E · Potential for more than minimal harm
2023-11-12
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-12-07
E · Potential for more than minimal harm
2023-11-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-12-07
E · Potential for more than minimal harm
2023-11-12
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 2023-12-07
E · Potential for more than minimal harm
2023-11-12
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 2023-12-07
E · 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 2023-12-07
D · Potential for more than minimal harm
2023-11-12
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 2023-12-07
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 2023-12-07
D · Potential for more than minimal harm
2023-11-12
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 2023-12-07
D · Potential for more than minimal harm
2023-11-12
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-12-07
D · Potential for more than minimal harm
2023-11-12
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 2023-12-07
D · Potential for more than minimal harm
2023-11-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-07
D · Potential for more than minimal harm
2023-11-12
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-12-07
D · Potential for more than minimal harm
2023-11-12
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 2023-12-07
D · Potential for more than minimal harm
2023-11-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-07
B · Minimal harm
2023-11-12
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 2023-12-07
D · Potential for more than minimal harm
2023-07-06
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 2023-07-21
D · Potential for more than minimal harm
2023-06-13
F844 · Administration Deficiencies
Health
Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
Corrected 2023-06-26
F · Potential for more than minimal harm
2021-12-09
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 2021-12-30
D · Potential for more than minimal harm
2021-12-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-12-30
D · Potential for more than minimal harm
2021-12-09
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 2021-12-30
D · Potential for more than minimal harm
2021-12-09
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 2021-12-30
D · Potential for more than minimal harm
2021-12-09
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2021-12-30
D · Potential for more than minimal harm
2021-12-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-30
D · Potential for more than minimal harm
2021-12-09
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2021-12-30
B · Minimal harm
2021-12-09
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 2022-04-15
Penalties and ownership
What sits behind the stars
Ownership
Colonial Post Acute LLC
5% Or Greater Direct Ownership Interest · Organization
Johnson, David
5% Or Greater Indirect Ownership Interest · Individual
Johnson, Frank
5% Or Greater Indirect Ownership Interest · Individual
Colonial Post Acute LLC
Operational/Managerial Control · Organization
Dehghanmanesh, Adrian
Operational/Managerial Control · Individual
Esquer, Albert
Operational/Managerial Control · Individual
Farrales, Mary
Operational/Managerial Control · Individual
Goldstar North Hollywood Associates LLC
5% Or Greater Security Interest · Organization
Johnson, David
Operational/Managerial Control · Individual
Johnson, Frank
Operational/Managerial Control · Individual
Johnson, Frank
Corporate Officer · Individual
Kochek, Joshua
Operational/Managerial Control · Individual
Oxford, Micheal
Operational/Managerial Control · Individual
Rodriguez, Krissia
Operational/Managerial Control · Individual
Rutherford, Keino
Operational/Managerial Control · Individual
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#3
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