Citrus Nursing Center
9440 Citrus Ave, Fontana, CA 92335 · San Bernardino County · 99 certified beds · avg 91 residents/day · certified since Jan 29, 1968
Part of chain: DAVID JOHNSON (48 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 5/5
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)
▲ Immediate jeopardy, one-off · Aug 30, 2023 · 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 (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Sep 23, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (22)
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 |
|---|---|---|
| Jul 31, 2025 | F · Potential for harm, facility-wide | 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. |
| Jul 31, 2025 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Jul 31, 2025 | 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. |
| Jul 31, 2025 | 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. |
| Jul 31, 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. |
| Jul 31, 2025 | 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. |
| Jul 31, 2025 | 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. |
| Dec 5, 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. · from a complaint |
| Aug 30, 2023 | ▲ J · Immediate jeopardy, 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 |
| Jun 10, 2022 | E · Potential for harm, repeated | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jun 10, 2022 | 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. |
| Jun 10, 2022 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Jun 10, 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. |
| Jun 10, 2022 | 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. |
| Jun 10, 2022 | 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. |
| Jun 10, 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. |
| Aug 23, 2019 | F · Potential for harm, facility-wide | 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. |
| Aug 23, 2019 | 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. |
| Aug 23, 2019 | 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. |
| Aug 23, 2019 | 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. |
| Aug 23, 2019 | 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. |
| Aug 23, 2019 | 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 stayed about the same across the last two inspection cycles (7 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 6 | 0 | F |
| 2022 | 7 | 0 | E |
| 2023 | 1 | 1 | J ▲ |
| 2024 | 1 | 0 | D |
| 2025 | 7 | 0 | F |
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 $7,446.
| Date | Type | Amount / length |
|---|---|---|
| Aug 30, 2023 | Fine | $7,446 |
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) | 3.64 | 4.31 | 3.95 | bottom 17% in California; bottom 44% in the U.S. |
| Registered Nurse hours | 0.28 | 0.61 | 0.69 | bottom 8% in California; bottom 7% in the U.S. |
| Weekend total nurse staffing | 3.38 | 3.90 | 3.50 | bottom 21% in California; top 48% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.24 | 0.51 | 0.48 | bottom 19% in California; bottom 19% in the U.S. |
| Total nursing staff turnover (%) | 32.2 | 36.7 | 45.8 | top 38% in California; top 18% in the U.S. |
| RN turnover (%) | 63.6 | 38.1 | 42.9 | bottom 12% in California; bottom 17% 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 4.02, RN 0.30, weekend 3.73. Staffing rating: 2/5.
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 - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Citrus Nursing Center | Organization | 5% or Greater Direct Ownership Interest | — | 12/24/1990 |
| Marmur, Eli | Individual | 5% or Greater Direct Ownership Interest | — | 12/24/1990 |
| Bernard-Butler, Esther | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| Cibc Bank USA | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/2021 |
| Citrus Nursing Center | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/06/1991 |
| Citrus Nursing Center | Organization | ADP of the SNF | NOT APPLICABLE | 01/06/1991 |
| De Jesus, Walter | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/18/2020 |
| De Jesus, Walter | Individual | ADP of the SNF | NOT APPLICABLE | 09/18/2020 |
| Dehghanmanesh, Adrian | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2021 |
| Dehghanmanesh, Adrian | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/01/2021 |
| Dehghanmanesh, Adrian | Individual | ADP of the SNF | NOT APPLICABLE | 06/01/2021 |
| Farrales, Mary | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2023 |
| Golboo, Sepehr | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2022 |
| Golboo, Sepehr | Individual | ADP of the SNF | NOT APPLICABLE | 05/22/2025 |
| Johnson, Frank | Individual | Corporate Director | NOT APPLICABLE | 12/24/1990 |
| Johnson, Frank | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/24/1990 |
| K-Regency, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/15/2024 |
| Kochek, Joshua | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2022 |
| Kochek, Joshua | Individual | ADP of the SNF | NOT APPLICABLE | 04/01/2022 |
| Oxford, Micheal | Individual | Corporate Officer | NOT APPLICABLE | 01/03/2022 |
Questions to ask on your visit
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 leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "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 |
|---|---|---|---|---|---|
| Laurel Convalescent Hospital | 3.3 mi | Fontana, CA | ★★★☆☆ | 3/5 | |
| Rialto Post Acute Center | 4.6 mi | Rialto, CA | ★★☆☆☆ | 2/5 | |
| Riverside Heights Healthcare Center, LLC | 4.7 mi | Riverside, CA | ★★★★★ | 5/5 | |
| Jurupa Hills Post Acute | 5.1 mi | Riverside, CA | ★★☆☆☆ | 2/5 | |
| Vista Pacifica Convalescent Hospital | 5.5 mi | Jurupa Valley, CA | ★★★★☆ | 3/5 | |
| Vista Pacifica Center | 5.6 mi | Jurupa Valley, CA | ★★★★☆ | 3/5 | |
| Riverside Postacute Care | 7.8 mi | Riverside, CA | —/5 | abuseSFF | |
| Community Convalescent Center of San Bernardino | 8.0 mi | San Bernardino, CA | ★★★★★ | 5/5 | |
| Community Hospital of San Bernardino DP SNF | 8.0 mi | San Bernardino, CA | ★★☆☆☆ | 3/5 | |
| Riverside Behavioral Healthcare Center | 8.0 mi | Riverside, CA | ★★★★★ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 055872.