Baldwin Gardens Nursing Center

Name: Baldwin Gardens Nursing Center
Address: 10786 LIVE OAK AVENUE, Temple City, CA, 91780, US
Telephone: 6264473553

10786 Live Oak Avenue, Temple City, CA 91780 · Los Angeles County · 59 certified beds · avg 55 residents/day · certified since Feb 1, 1977

Part of chain: ABRAHAM BAK & MENACHEM GASTWIRTH (18 facilities, chain avg rating 2.5★)

4/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

5.01

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★☆4/5 · CMS overall rating: 4/5

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.

All citations in the current public record (38)

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 24, 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. · from a complaint
Jun 24, 2026	D · Potential for harm, one-off	The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · from a complaint
Jun 24, 2026	D · Potential for harm, one-off	The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint
Jan 30, 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.
Jan 30, 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.
Jan 30, 2026	D · Potential for harm, one-off	The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Jan 30, 2026	D · Potential for harm, one-off	The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay).
Jan 30, 2026	D · Potential for harm, one-off	The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way.
Jan 30, 2026	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jan 30, 2026	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Jan 30, 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.
Mar 11, 2025	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Dec 18, 2024	D · Potential for harm, one-off	The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint
Nov 22, 2024	E · Potential for harm, repeated	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Nov 22, 2024	E · Potential for harm, 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.
Nov 22, 2024	E · Potential for harm, repeated	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Nov 22, 2024	E · Potential for harm, repeated	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Nov 22, 2024	E · Potential for harm, repeated	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.
Nov 22, 2024	E · Potential for harm, repeated	The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
Nov 22, 2024	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.
Nov 22, 2024	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Nov 22, 2024	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.
Nov 22, 2024	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.
Nov 22, 2024	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Nov 22, 2024	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Nov 22, 2024	B · Minimal risk, repeated	The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day.
Dec 3, 2023	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Dec 3, 2023	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.
Dec 3, 2023	E · Potential for harm, repeated	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Dec 3, 2023	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Dec 3, 2023	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.
Dec 3, 2023	D · Potential for harm, one-off	The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Dec 3, 2023	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Dec 3, 2023	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.
Dec 3, 2023	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.
Dec 3, 2023	D · Potential for harm, one-off	The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems.
Dec 3, 2023	D · Potential for harm, one-off	The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows.
Dec 3, 2023	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.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (13 → 8).

Year	Citations	Worst severity that year
2023	12	E
2024	14	E
2025	1	D
2026	11	E

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)

No fines or payment denials in the published 3-year window.

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)	5.01	4.31	3.95	top 14% in California; top 13% in the U.S.
Registered Nurse hours	0.39	0.61	0.69	bottom 31% in California; bottom 21% in the U.S.
Weekend total nurse staffing	4.57	3.90	3.50	top 12% in California; top 11% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.35	0.51	0.48	bottom 46% in California; bottom 42% in the U.S.
Total nursing staff turnover (%)	24.3	36.7	45.8	top 16% in California; top 6% in the U.S.
RN turnover (%)	40.0	38.1	42.9	bottom 47% in California; top 46% 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 5.64, RN 0.44, weekend 5.14. Staffing rating: 4/5.

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: 2/5 · long-stay residents: 3/5 · short-stay residents: 1/5

Who owns this facility

Government - Federal

Owner / manager	Type	Role	Stake	Since
Lehmann, Kenneth	Individual	5% or Greater Direct Ownership Interest	24%	03/13/2020
Abak Consulting LLC	Organization	ADP of the SNF	NOT APPLICABLE	12/27/2021
Bak, Abraham	Individual	Corporate Director	NOT APPLICABLE	03/13/2020
Bak, Abraham	Individual	ADP of the SNF	NOT APPLICABLE	12/27/2021
Bastomski Living Trust Dated April 18, 1997	Organization	ADP of the SNF	NOT APPLICABLE	04/02/2007
Bastomski, Israel	Individual	ADP of the SNF	NOT APPLICABLE	04/02/2007
Gastwirth, Menachem	Individual	Corporate Director	NOT APPLICABLE	03/13/2020
Gastwirth, Menachem	Individual	ADP of the SNF	NOT APPLICABLE	12/27/2021
Gewirtz, Chonoch	Individual	Corporate Officer	NOT APPLICABLE	03/13/2020
Gewirtz, Chonoch	Individual	ADP of the SNF	NOT APPLICABLE	12/27/2021
Horowicz, Avi	Individual	Operational/Managerial Control	NOT APPLICABLE	08/27/2024
Horowicz, Avi	Individual	ADP of the SNF	NOT APPLICABLE	05/21/2025
Lehmann, Kenneth	Individual	Corporate Director	NOT APPLICABLE	03/13/2020
Lehmann, Kenneth	Individual	ADP of the SNF	NOT APPLICABLE	12/27/2021
Live Oak TC 1, LLC	Organization	ADP of the SNF	NOT APPLICABLE	04/02/2007
Live Oak TC 2, LLC	Organization	ADP of the SNF	NOT APPLICABLE	04/02/2007
Mayer 2005 Revocable Trust	Organization	ADP of the SNF	NOT APPLICABLE	04/02/2007
Mayer, Helene	Individual	ADP of the SNF	NOT APPLICABLE	04/02/2007
Mayer, Ronald	Individual	ADP of the SNF	NOT APPLICABLE	04/02/2007
Mgaz Consulting LLC	Organization	ADP of the SNF	NOT APPLICABLE	12/27/2021

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"Can you show me an example care plan, and how are families included when it's created and updated?"
"How do you handle residents who need modified food textures, and how do you make those meals appetizing?"
"Can you show me the call buttons in the bathrooms and bathing areas, and tell me your average response time when one is pressed?"
"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?"
"How do you explain health changes and treatment options to residents and their families?"
"What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
"If my family member's health suddenly changes, how quickly do you reassess them and update their care?"
"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
Santa Anita Convalescent Hospital	0.2 mi	Temple City, CA	★☆☆☆☆	1/5	SFF
Temple City Healthcare	1.2 mi	Temple City, CA	★★☆☆☆	2/5
Arcadia Care Center	1.3 mi	Arcadia, CA	★★☆☆☆	2/5
Rosemead Healthcare Center	1.6 mi	El Monte, CA	★★☆☆☆	2/5
San Marino Healthcare Center	1.7 mi	San Gabriel, CA	★★★☆☆	2/5	abuse
Huntington Drive Health and Rehabilitation Center	1.8 mi	Arcadia, CA	★☆☆☆☆	1/5
Fidelity Health Care	1.9 mi	El Monte, CA	★★★☆☆	2/5	abuse
Pine Grove Healthcare & Wellness Centre, LP	2.3 mi	San Gabriel, CA	★★★★☆	3/5
Santa Fe Lodge	2.3 mi	El Monte, CA	★★☆☆☆	2/5
Mayflower Care Center	2.3 mi	El Monte, CA	★★★☆☆	3/5
The Gardens of el Monte	2.4 mi	El Monte, CA	★★☆☆☆	2/5
Mission Care Center	2.5 mi	Rosemead, CA	★★★★☆	3/5

Compare this facility with the 3 closest →

All facilities in Temple City →

Facility data as of CMS processing date 2026-08-01. CCN 555055.

The Care File

Visit checklist — Baldwin Gardens Nursing Center

10786 Live Oak Avenue, Temple City, CA 91780 · 6264473553

Health inspection rating 4/5 · CMS overall 4/5· Fines (3y): $0

Questions for the administrator:

☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "How do you handle residents who need modified food textures, and how do you make those meals appetizing?"
☐ "Can you show me the call buttons in the bathrooms and bathing areas, and tell me your average response time when one is pressed?"
☐ "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?"
☐ "How do you explain health changes and treatment options to residents and their families?"
☐ "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
☐ "If my family member's health suddenly changes, how quickly do you reassess them and update their care?"
☐ "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?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 555055 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)