Alta Gardens Care Center
13075 Blackbird Street, Garden Grove, CA 92843 · Orange County · 129 certified beds · avg 118 residents/day · certified since Jul 30, 1999
Part of chain: WINDSOR (22 facilities, chain avg rating 2.4★)
2/5
Health inspection rating (on-site)
1
Serious findings on record
$8,278
Fines, last 3 years
3.85
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Mar 11, 2026 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 27, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (59)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 1, 2026 | D · Potential for harm, one-off | The facility was not properly licensed, or did not operate in compliance with federal, state, and local laws, regulations, and accepted professional standards. · from a complaint |
| Mar 11, 2026 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Feb 18, 2026 | E · Potential for harm, repeated | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Feb 18, 2026 | E · Potential for harm, repeated | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Feb 18, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 18, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 18, 2026 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Feb 18, 2026 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Feb 18, 2026 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 18, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Feb 18, 2026 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Feb 18, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Feb 18, 2026 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Feb 18, 2026 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. |
| Feb 18, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Feb 18, 2026 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Feb 18, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Feb 18, 2026 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 18, 2026 | D · Potential for harm, one-off | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| Feb 18, 2026 | D · Potential for harm, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Feb 18, 2026 | D · Potential for harm, one-off | The facility did not provide residents with enough to drink, or with drinks matching their needs and preferences, to keep them properly hydrated. |
| Feb 18, 2026 | D · Potential for harm, one-off | The facility did not have a policy covering how food brought in by family and visitors is used and stored safely. |
| Feb 18, 2026 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Feb 18, 2026 | D · Potential for harm, one-off | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Feb 18, 2026 | B · Minimal risk, repeated | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Feb 18, 2026 | B · Minimal risk, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Feb 18, 2026 | B · Minimal risk, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Feb 18, 2026 | B · Minimal risk, repeated | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. |
| Feb 18, 2025 | E · Potential for harm, repeated | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. |
| Feb 18, 2025 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility did not have a policy covering how food brought in by family and visitors is used and stored safely. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 18, 2025 | B · Minimal risk, repeated | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Feb 18, 2025 | B · Minimal risk, repeated | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Feb 18, 2025 | B · Minimal risk, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Feb 18, 2025 | B · Minimal risk, repeated | The facility did not dispose of garbage and refuse properly. |
| Jan 7, 2025 | B · Minimal risk, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jun 5, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 20, 2022 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Sep 20, 2022 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 20, 2022 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Sep 20, 2022 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Sep 20, 2022 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Sep 20, 2022 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Sep 20, 2022 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Sep 20, 2022 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Sep 20, 2022 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 20, 2022 | D · Potential for harm, one-off | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (19 → 26).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 10 | 0 | E |
| 2024 | 1 | 0 | D |
| 2025 | 20 | 0 | E |
| 2026 | 28 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $8,278.
| Date | Type | Amount / length |
|---|---|---|
| Feb 18, 2026 | Fine | $8,278 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | California avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.85 | 4.31 | 3.95 | bottom 31% in California; top 46% in the U.S. |
| Registered Nurse hours | 0.51 | 0.61 | 0.69 | top 46% in California; bottom 39% in the U.S. |
| Weekend total nurse staffing | 3.58 | 3.90 | 3.50 | bottom 36% in California; top 39% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.37 | 0.51 | 0.48 | bottom 50% in California; bottom 46% in the U.S. |
| Total nursing staff turnover (%) | 20.4 | 36.7 | 45.8 | top 8% in California; top 3% in the U.S. |
| RN turnover (%) | 33.3 | 38.1 | 42.9 | top 40% in California; top 33% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.87, RN 0.51, weekend 3.59. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bold Quail 3 Operations Holdings, LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 03/03/2025 |
| Bold Quail 3 Realty Holdings, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 01/22/2024 |
| Bold Quail 3, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 03/03/2025 |
| Newgen LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 03/03/2025 |
| Robin, Aaron | Individual | 5% or Greater Indirect Ownership Interest | — | 03/03/2025 |
| Tress, Avrohom | Individual | 5% or Greater Indirect Ownership Interest | — | 03/03/2025 |
| 13075 Blackbird Street Propco, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/03/2025 |
| 9560 Pico LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/03/2025 |
| Bold Quail 3 Realty Holdings, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/03/2025 |
| Bold Quail 3, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/03/2025 |
| Kieu, Triet | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/14/2020 |
| Kieu, Triet | Individual | ADP of the SNF | NOT APPLICABLE | 09/14/2020 |
| Newgen Administrative Services, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/03/2025 |
| Newgen LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/03/2025 |
| Pacrim, Sweet Jean | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/15/2024 |
| Pacrim, Sweet Jean | Individual | ADP of the SNF | NOT APPLICABLE | 07/15/2024 |
| Pico Ar LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/03/2025 |
| Robin, Aaron | Individual | Corporate Officer | NOT APPLICABLE | 08/28/2025 |
| Robin, Aaron | Individual | ADP of the SNF | NOT APPLICABLE | 03/03/2025 |
| Shaw, Pamela | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/06/2026 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Can you tell me about this citation and confirm your license and compliance status today?"
- "How do you explain health changes and treatment options to residents and their families?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Garden Park Care Center | 0.4 mi | Garden Grove, CA | ★★★★☆ | 3/5 | |
| The Grove Post Acute | 0.6 mi | Garden Grove, CA | ★★★★★ | 4/5 | |
| Pacific Haven Subacute and Healthcare Center | 0.7 mi | Garden Grove, CA | ★★★★☆ | 3/5 | |
| Citrus Post-Acute | 0.9 mi | Santa Ana, CA | ★★☆☆☆ | 2/5 | |
| Chapman Care Center | 1.2 mi | Garden Grove, CA | ★★★★☆ | 4/5 | |
| Mainplace Post Acute | 2.4 mi | Orange, CA | ★★☆☆☆ | 2/5 | |
| Coventry Court Health Center | 2.8 mi | Anaheim, CA | ★★★★☆ | 3/5 | |
| Town & Country | 2.9 mi | Santa Ana, CA | ★★★★★ | 3/5 | |
| Orange Healthcare & Wellness Centre, LLC | 2.9 mi | Orange, CA | ★★★☆☆ | 3/5 | |
| French Park Care Center | 3.1 mi | Santa Ana, CA | ★☆☆☆☆ | 1/5 | |
| Buena Vista Care Center | 3.1 mi | Anaheim, CA | ★★★☆☆ | 3/5 | |
| Garden Grove Post Acute | 3.5 mi | Garden Grove, CA | ★★★★☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 555473.