California ›San Gabriel

Broadway Healthcare Center

112 E. Broadway, San Gabriel, CA 91776 · Los Angeles County · 59 certified beds · avg 56 residents/day · certified since Sep 22, 1971

Part of chain: CAMBRIDGE HEALTHCARE SERVICES (32 facilities, chain avg rating 2.5★)

3/5
Health inspection rating (on-site)
1
Serious findings on record
$3,145
Fines, last 3 years
3.80
Nurse hours/resident/day (adjusted)

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

Health inspection rating: ★★★☆☆3/5 · 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 · Jan 24, 2025 · F-0689

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

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: Feb 14, 2025 (Deficient, Provider has date of correction)

All citations in the current public record (43)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Feb 6, 2026F · Potential for harm, facility-wideThe 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 6, 2026E · Potential for harm, repeatedThe 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 6, 2026E · Potential for harm, repeatedThe 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.
Feb 6, 2026D · Potential for harm, one-offThe 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.
Feb 6, 2026D · Potential for harm, one-offThe 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 6, 2026D · Potential for harm, one-offThe 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 6, 2026D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Feb 6, 2026D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Feb 6, 2026D · Potential for harm, one-offThe 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 6, 2026D · Potential for harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it.
Feb 6, 2026D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Feb 6, 2026B · Minimal risk, repeatedThe facility had resident rooms holding more people than allowed — no more than 4 residents per room, and no more than 2 per room in buildings constructed after November 28, 2016.
Feb 6, 2026B · Minimal risk, repeatedThe facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms.
Jan 24, 2025▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jan 24, 2025E · Potential for harm, repeatedThe 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 24, 2025D · Potential for harm, one-offThe facility did not keep residents' personal and medical information private and confidential.
Jan 24, 2025D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jan 24, 2025D · Potential for harm, one-offThe 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.
Jan 24, 2025D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Jan 24, 2025D · Potential for harm, one-offThe facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have.
Jan 24, 2025D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Jan 24, 2025D · Potential for harm, one-offThe 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.
Jan 24, 2025D · Potential for harm, one-offThe 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.
Jan 24, 2025D · Potential for harm, one-offThe 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 24, 2025B · Minimal risk, repeatedThe 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.
Jan 24, 2025B · Minimal risk, repeatedThe facility had resident rooms holding more people than allowed — no more than 4 residents per room, and no more than 2 per room in buildings constructed after November 28, 2016.
Jan 24, 2025B · Minimal risk, repeatedThe facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms.
Jan 19, 2024E · Potential for harm, repeatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Jan 19, 2024E · Potential for harm, repeatedThe 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.
Jan 19, 2024E · Potential for harm, repeatedThe 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.
Jan 19, 2024E · Potential for harm, repeatedThe 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 19, 2024E · Potential for harm, repeatedThe 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 19, 2024E · Potential for harm, repeatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
Jan 19, 2024D · Potential for harm, one-offThe 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.
Jan 19, 2024D · Potential for harm, one-offThe 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.
Jan 19, 2024D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Jan 19, 2024D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jan 19, 2024D · Potential for harm, one-offThe facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them.
Jan 19, 2024D · Potential for harm, one-offThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Jan 19, 2024D · Potential for harm, one-offThe facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing.
Jan 19, 2024D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Jan 19, 2024B · Minimal risk, repeatedThe facility had resident rooms holding more people than allowed — no more than 4 residents per room, and no more than 2 per room in buildings constructed after November 28, 2016.
Jan 19, 2024B · Minimal risk, repeatedThe facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (14 → 13).

YearCitationsSerious (G–L)Worst severity that year
2024160E
2025141G ▲
2026130F

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 $3,145.

DateTypeAmount / length
Sep 5, 2023Fine$3,145

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityCalifornia avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.804.313.95bottom 27% in California; top 48% in the U.S.
Registered Nurse hours0.360.610.69bottom 23% in California; bottom 16% in the U.S.
Weekend total nurse staffing3.703.903.50bottom 47% in California; top 33% in the U.S.
Weekend RN hours (not acuity-adjusted)0.270.510.48bottom 26% in California; bottom 25% in the U.S.
Total nursing staff turnover (%)21.436.745.8top 10% in California; top 4% in the U.S.
RN turnover (%)0.038.142.9—

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 3.86, RN 0.37, weekend 3.76. 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: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Ag Facilities Operations, LLCOrganization5% or Greater Direct Ownership Interest100%07/24/2003
Ira E Smedra Living TrustOrganization5% or Greater Indirect Ownership Interest48%07/24/2003
Win Win Enterprises, LLCOrganization5% or Greater Indirect Ownership Interest48%07/24/2003
112 E. Broadway, LLCOrganizationADP of the SNFNOT APPLICABLE10/01/2023
Butenko, JulieIndividualOperational/Managerial ControlNOT APPLICABLE07/24/2023
Butenko, JulieIndividualADP of the SNFNOT APPLICABLE07/24/2023
Cambridge Healthcare Services LLCOrganizationOperational/Managerial ControlNOT APPLICABLE06/11/2018
Cambridge Healthcare Services LLCOrganizationADP of the SNFNOT APPLICABLE06/11/2018
Capela, HeidiIndividualOperational/Managerial ControlNOT APPLICABLE04/03/2023
Capela, HeidiIndividualADP of the SNFNOT APPLICABLE04/03/2023
Chien, OscarIndividualOperational/Managerial ControlNOT APPLICABLE09/09/2013
Chien, OscarIndividualADP of the SNFNOT APPLICABLE09/09/2013
Gimino, RovelynIndividualOperational/Managerial ControlNOT APPLICABLE02/28/2025
Hassell, LanceIndividualOperational/Managerial ControlNOT APPLICABLE04/25/2022
Hassell, LanceIndividualADP of the SNFNOT APPLICABLE04/25/2022
Lutz, LindaIndividualOperational/Managerial ControlNOT APPLICABLE02/01/2012
Lutz, LindaIndividualADP of the SNFNOT APPLICABLE02/01/2012
Moore, AmandaIndividualManaging Control - Governing BodyNOT APPLICABLE05/08/2023
Moore, AmandaIndividualOperational/Managerial ControlNOT APPLICABLE05/08/2023
Moore, AmandaIndividualADP of the SNFNOT APPLICABLE05/08/2023

Questions to ask on your visit

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

Nearby facilities (within 20 miles)

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Pine Grove Healthcare & Wellness Centre, LP0.7 miSan Gabriel, CA★★★★☆3/5
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Alhambra Healthcare & Wellness Centre, LP1.3 miAlhambra, CA★★★☆☆2/5
Atherton Baptist Home1.9 miAlhambra, CA★★★★★4/5
Del Mar Convalescent Hospital2.3 miRosemead, CA★★★★★4/5
San Marino Healthcare Center2.4 miSan Gabriel, CA★★★☆☆2/5abuse
Alhambra Hospital Med Ctr DP/SNF2.4 miAlhambra, CA★★★★☆4/5
Heritage Manor2.4 miMonterey Park, CA★★☆☆☆1/5

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Facility data as of CMS processing date 2026-08-01. CCN 056201.