California ›San Diego

Carmel Mountain Rehabilitation & Healthcare Center

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11895 Avenue of Industry, San Diego, CA 92128 (opens Google Maps) · San Diego County · (858) 673-0101· 120 certified beds · avg 115 residents/day · certified since Oct 12, 1988 · Medicare and Medicaid certified

Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →

Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)

2/5
Health inspection rating (on-site)
inspected Apr 24, 2025
1
Serious findings on record
most recent Apr 15, 2026
$0
Fines, last 3 years
3.62
Nurse hours/resident/day (adjusted)

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

New to these records? How to read an inspection report →

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5 · how star ratings work →

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 quality measures from resident assessments and claims.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, isolated · Apr 15, 2026 · F-0689 · triggered by a complaint

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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: May 4, 2026 (Deficient, Provider has date of correction)

Inspection findings in the public record

Showing the latest 3 of 53 inspection findings. Open the full record below to read every finding.

  1. G · Actual harm, isolated

    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 F-0689

  2. D · Potential for more than minimal harm, isolated

    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. · from a complaint F-0657

  3. D · Potential for more than minimal harm, isolated

    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 F-0684

View all 53 inspection findingsShow only the latest 3 findings

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.

DateSeverityWhat the facility was cited for
Apr 15, 2026▲ G · Actual harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Apr 15, 2026D · Potential for more than minimal harm, isolatedThe 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. · from a complaint · F-0657
Apr 15, 2026D · Potential for more than minimal harm, isolatedThe 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 · F-0684
Jan 22, 2026E · Potential for more than minimal harm, patternThe 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 · F-0880
Sep 16, 2025D · Potential for more than minimal harm, isolatedThe 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. · from a complaint · F-0550
Sep 16, 2025D · Potential for more than minimal harm, isolatedThe 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 · F-0880
Sep 4, 2025E · Potential for more than minimal harm, patternThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint · F-0755
Sep 4, 2025D · Potential for more than minimal harm, isolatedThe 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 · F-0684
Sep 4, 2025D · Potential for more than minimal harm, isolatedThe facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint · F-0835
Apr 24, 2025E · Potential for more than minimal harm, patternThe 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. · F-0558
Apr 24, 2025E · Potential for more than minimal harm, patternThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · F-0584
Apr 24, 2025E · Potential for more than minimal harm, patternThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812
Apr 24, 2025E · Potential for more than minimal harm, patternThe facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. · F-0865
Apr 24, 2025E · Potential for more than minimal harm, patternThe 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. · F-0880
Apr 24, 2025D · Potential for more than minimal harm, isolatedThe facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. · F-0561
Apr 24, 2025D · Potential for more than minimal harm, isolatedThe 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 · F-0656
Apr 24, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684
Apr 24, 2025D · Potential for more than minimal harm, isolatedThe 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. · F-0686
Apr 24, 2025D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Apr 24, 2025D · Potential for more than minimal harm, isolatedThe 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. · F-0690
Apr 24, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · F-0698
Apr 24, 2025D · Potential for more than minimal harm, isolatedThe 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. · F-0758
Apr 24, 2025D · Potential for more than minimal harm, isolatedThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · F-0842
Dec 26, 2024E · Potential for more than minimal harm, patternThe 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 · F-0656
Oct 15, 2024D · Potential for more than minimal harm, isolatedThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint · F-0641
Oct 15, 2024D · Potential for more than minimal harm, isolatedThe facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint · F-0655
Sep 13, 2024D · Potential for more than minimal harm, isolatedThe 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. · from a complaint · F-0808
Sep 13, 2024D · Potential for more than minimal harm, isolatedThe 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 · F-0880
Jul 30, 2024D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
May 10, 2024E · Potential for more than minimal harm, patternThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812
May 10, 2024E · Potential for more than minimal harm, patternThe 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. · F-0880
May 10, 2024D · Potential for more than minimal harm, isolatedThe 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. · F-0550
May 10, 2024D · Potential for more than minimal harm, isolatedThe 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. · F-0554
May 10, 2024D · Potential for more than minimal harm, isolatedThe 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. · F-0558
May 10, 2024D · Potential for more than minimal harm, isolatedThe 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. · F-0578
May 10, 2024D · Potential for more than minimal harm, isolatedThe facility did not keep residents' personal and medical information private and confidential. · F-0583
May 10, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · F-0584
May 10, 2024D · Potential for more than minimal harm, isolatedThe 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. · F-0656
May 10, 2024D · Potential for more than minimal harm, isolatedThe 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. · F-0677
May 10, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684
May 10, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. · F-0688
May 10, 2024D · Potential for more than minimal harm, isolatedThe 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. · F-0693
May 10, 2024D · Potential for more than minimal harm, isolatedThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · F-0726
May 10, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · F-0755
May 10, 2024D · Potential for more than minimal harm, isolatedThe 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. · F-0761
May 10, 2024D · Potential for more than minimal harm, isolatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · F-0921
Jul 28, 2023D · Potential for more than minimal harm, isolatedThe 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. · F-0558
Jul 28, 2023D · Potential for more than minimal harm, isolatedThe 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. · F-0656
Jul 28, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. · F-0699
Jul 28, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · F-0755
Jul 28, 2023D · Potential for more than minimal harm, isolatedThe 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. · F-0758
Jul 28, 2023D · Potential for more than minimal harm, isolatedThe 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. · F-0759
Jul 28, 2023D · Potential for more than minimal harm, isolatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (17 → 14).

Citations by recorded inspection yearPublished citation counts, not a quality score · Source: CMS, 2026-08-01
All citationsSerious citations (G–L)
2023
All citations: 7
Serious citations (G–L): 0
2024
All citations: 23
Serious citations (G–L): 0
2025
All citations: 19
Serious citations (G–L): 0
2026
All citations: 4
Serious citations (G–L): 1

All bars start at zero. Exact values and supporting details remain below.

YearCitationsSerious (G–L)Worst severity that year
202370D
2024230E
2025190E
202641G ▲

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)

How to file a complaint about care →

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

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

What these staffing numbers mean →

Nurse time, in contextAdjusted hours per resident per day · Source: CMS, 2026-08-01
This facilityCalifornia averageU.S. average
Total nurse staffing (hours per resident per day)
This facility: 3.62
California average: 4.31
U.S. average: 3.95
Registered Nurse hours
This facility: 0.69
California average: 0.61
U.S. average: 0.69
Weekend total nurse staffing
This facility: 3.32
California average: 3.90
U.S. average: 3.50

All bars start at zero. Exact values and supporting details remain below.

MeasureThis facilityCalifornia avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.624.313.95bottom 16% in California; bottom 43% in the U.S.
Registered Nurse hours0.690.610.69top 24% in California; top 37% in the U.S.
Weekend total nurse staffing3.323.903.50bottom 18% in California; bottom 48% in the U.S.
Weekend RN hours (not acuity-adjusted)0.830.510.48top 11% in California; top 10% in the U.S.
Total nursing staff turnover (%)40.036.745.8bottom 38% in California; top 36% in the U.S.
RN turnover (%)37.938.142.9bottom 48% in California; top 44% in the U.S.

Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — 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 5.02, RN 0.96, weekend 4.61.Comparing with Medicare Care Compare? Care Compare shows the raw figure (5.02 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 3/5.

Quality measures: assessments & claims

Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5

Costs & payment

Price evidence · separate from quality

No verified facility-specific private-pay price is available in our data for Carmel Mountain Rehabilitation & Healthcare Center. CMS inspection and staffing records do not tell us what this home will charge you.

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Who owns this facility

How to read ownership records →

Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Burnam, SoonIndividualManaging Control - Governing BodyNOT APPLICABLE09/09/2024
Burnam, SoonIndividualCorporate OfficerNOT APPLICABLE09/09/2024
Caretrust GP LLCOrganizationADP of the SNFNOT APPLICABLE03/01/2006
Caretrust Reit INCOrganizationADP of the SNFNOT APPLICABLE03/01/2006
Cetna Staffing INCOrganizationOperational/Managerial ControlNOT APPLICABLE03/01/2006
CM Health Holdings LLCOrganizationADP of the SNFNOT APPLICABLE03/01/2006
Ctr Partnership LPOrganizationADP of the SNFNOT APPLICABLE03/01/2006
Ensign Services INCOrganizationADP of the SNFNOT APPLICABLE03/01/2006
Kalafer, MichaelIndividualManaging Control - Governing BodyNOT APPLICABLE03/22/2016
Kalafer, MichaelIndividualOperational/Managerial ControlNOT APPLICABLE03/22/2016
Kalafer, MichaelIndividualADP of the SNFNOT APPLICABLE03/22/2016
Keetch, ChadIndividualCorporate OfficerNOT APPLICABLE03/01/2011
Lincare INCOrganizationOperational/Managerial ControlNOT APPLICABLE03/01/2006
Matthews, GlennIndividualManaging Control - Governing BodyNOT APPLICABLE04/01/2013
Matthews, GlennIndividualOperational/Managerial ControlNOT APPLICABLE04/01/2013
Matthews, GlennIndividualADP of the SNFNOT APPLICABLE04/01/2013
Oh, KatherineIndividualCorporate OfficerNOT APPLICABLE09/09/2024
Port, BarryIndividualCorporate DirectorNOT APPLICABLE01/22/2015
Sato, AmiIndividualCorporate OfficerNOT APPLICABLE09/09/2024
Sevenoaks Capital Associates LLCOrganizationOperational/Managerial ControlNOT APPLICABLE03/01/2006

Showing 20 of 22 parties CMS has on file for this facility; 2 are not displayed. The full list is in the CMS Ownership dataset.

Other facilities in the same chain

CMS lists this facility under the chain The Ensign Group — 342 facilities in the current records. Chain membership says who operates these homes. It says nothing about how any individual one of them was inspected; each has its own record.

Listed by state, then facility name — not a ranking. Showing 8 of the 341 others, continuing from this facility's own place in that list.

Questions to ask on your visit

Full visit checklist →

Print visit checklist

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

  • "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
  • "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
  • "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
  • "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
  • "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
  • "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
  • "What were the findings behind this administration citation, and what has leadership changed since?"
  • "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"

Also worth asking anywhere

  • "Your weekend nurse staffing is reported below the California midpoint — how does the weekend schedule differ from a weekday?"
  • "Can I see the plan of correction for the findings in your most recent state inspection?"
  • "CMS reports 40% total nursing staff turnover here — who on the care team has been with you longest?"
  • "The ownership record on file lists 22 owning or managing parties — who makes the decisions about staffing levels?"
  • "Can I visit again unannounced, at a mealtime or on a weekend?"

Nearby facilities (12 closest of 69 within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Villa Rancho Bernardo Care Center1.1 miSan Diego, CA★★★★★4/5
Poway Healthcare Center1.3 miPoway, CA★★★★☆4/5
The Villas at Poway1.3 miPoway, CA★★★★★3/5
Boulder Creek Post Acute1.8 miPoway, CA★★★★☆3/5
Casa de Las Campanas4.1 miSan Diego, CA★★☆☆☆2/5
Ocean View Post Acute7.4 miEscondido, CA★★★★☆3/5
Redwood Terrace Health Center8.0 miEscondido, CA★★★★★5/5
Valley Vista Post Acute8.5 miEscondido, CA★★★★☆3/5
Bayshire Torrey Pines Post-Acute9.0 miSan Diego, CA★★★★★4/5
Palomar Vista Healthcare Center9.4 miEscondido, CA★★☆☆☆2/5
Palomar Heights Post Acute9.6 miEscondido, CA★★★☆☆2/5
Escondido Post Acute9.8 miEscondido, CA★★★★★4/5

Compare this facility with the 3 closest →

Other facilities in the same county

CMS records place this facility in San Diego, CA — 83 certified facilities there. These are outside the 20-mile list above, or far enough down it not to appear.

Listed by facility name — not a ranking. Homes already in the table above are not repeated here.

All facilities in San Diego →

Facility data as of CMS processing date 2026-08-01. CCN 555326.

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