California ›Pomona

Country Oaks Care Center

215 W Pearl St, Pomona, CA 91768 · Los Angeles County · 81 certified beds · avg 72 residents/day · certified since Nov 1, 1971

Part of chain: DAVID JOHNSON (48 facilities, chain avg rating 3.2★)

2/5
Health inspection rating (on-site)
0
Serious findings on record
$0
Fines, last 3 years
4.35
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.

All citations in the current public record (70)

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
May 8, 2026E · Potential for harm, repeatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
May 8, 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.
May 8, 2026E · 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.
May 8, 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.
May 8, 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.
May 8, 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.
May 8, 2026D · Potential for harm, one-offThe 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.
May 8, 2026D · Potential for harm, one-offThe 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.
Apr 16, 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. · from a complaint
Mar 24, 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. · from a complaint
Jul 17, 2025E · Potential for harm, repeatedThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
Jul 17, 2025D · 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. · from a complaint
Jul 17, 2025D · 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. · from a complaint
Apr 16, 2025E · Potential for harm, repeatedThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Apr 16, 2025D · 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. · from a complaint
Apr 16, 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. · from a complaint
Mar 6, 2025E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Mar 6, 2025E · Potential for harm, repeatedThe 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.
Mar 6, 2025E · Potential for harm, repeatedThe facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them.
Mar 6, 2025E · 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.
Mar 6, 2025E · 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.
Mar 6, 2025E · Potential for harm, repeatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Mar 6, 2025D · 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.
Mar 6, 2025D · Potential for harm, one-offThe 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.
Mar 6, 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.
Mar 6, 2025D · 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.
Mar 6, 2025D · 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.
Mar 6, 2025D · Potential for harm, one-offThe 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.
Mar 6, 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.
Mar 6, 2025D · Potential for harm, one-offThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Mar 6, 2025D · Potential for harm, one-offThe 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.
Mar 6, 2025D · Potential for harm, one-offThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Mar 6, 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.
Feb 19, 2025D · 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. · from a complaint
Feb 19, 2025D · Potential for harm, one-offThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
Oct 29, 2024D · Potential for harm, one-offThe 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
Oct 23, 2024D · Potential for harm, one-offThe facility did not provide timely, approved x-ray services or have an agreement with an approved provider to supply them. · from a complaint
Sep 25, 2024E · Potential for harm, repeatedThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
Aug 28, 2024E · Potential for harm, repeatedThe 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. · from a complaint
Aug 28, 2024E · Potential for harm, repeatedThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Aug 28, 2024D · Potential for harm, one-offThe 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. · from a complaint
Aug 12, 2024E · Potential for harm, repeatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Aug 1, 2024D · Potential for harm, one-offThe facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint
Jul 27, 2024D · 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. · from a complaint
Jul 15, 2024E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Jul 15, 2024D · 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. · from a complaint
Jul 15, 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. · from a complaint
Jun 11, 2024D · Potential for harm, one-offThe 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
May 7, 2024D · Potential for harm, one-offThe 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
Apr 17, 2024E · Potential for harm, repeatedThe 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. · from a complaint
Apr 17, 2024D · 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. · from a complaint
Mar 19, 2024E · Potential for harm, repeatedThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Mar 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. · from a complaint
Mar 7, 2024E · Potential for harm, repeatedThe 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
Feb 23, 2024E · Potential for harm, repeatedThe 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 23, 2024E · Potential for harm, repeatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Feb 23, 2024E · Potential for harm, repeatedThe 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 23, 2024E · Potential for harm, repeatedThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Feb 23, 2024E · Potential for harm, repeatedThe 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 23, 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.
Feb 23, 2024D · 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 23, 2024D · Potential for harm, one-offThe 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.
Feb 23, 2024D · 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.
Feb 23, 2024D · Potential for harm, one-offThe 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.
Feb 23, 2024D · Potential for harm, one-offThe 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 23, 2024D · Potential for harm, one-offThe 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
Feb 23, 2024D · Potential for harm, one-offThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Feb 23, 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.
Dec 26, 2023D · Potential for harm, one-offThe 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
Dec 26, 2023D · Potential for harm, one-offThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (17 → 8).

YearCitationsSerious (G–L)Worst severity that year
202320D
2024330E
2025250E
2026100E

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)

MeasureThis facilityCalifornia avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)4.354.313.95top 36% in California; top 28% in the U.S.
Registered Nurse hours0.450.610.69bottom 44% in California; bottom 30% in the U.S.
Weekend total nurse staffing3.873.903.50top 41% in California; top 27% in the U.S.
Weekend RN hours (not acuity-adjusted)0.390.510.48top 47% in California; bottom 49% in the U.S.
Total nursing staff turnover (%)52.536.745.8bottom 10% in California; bottom 31% in the U.S.
RN turnover (%)61.538.142.9bottom 14% in California; bottom 20% 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 4.40, RN 0.45, weekend 3.91. 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 / managerTypeRoleStakeSince
Chambers, ThomasIndividualIndirect Ownership InterestNOT APPLICABLE06/10/2008
Country Oaks Partners LLCOrganization5% or Greater Direct Ownership Interest100%11/05/2008
Johnson, DavidIndividualIndirect Ownership InterestNOT APPLICABLE06/10/2008
Johnson, FrankIndividualIndirect Ownership InterestNOT APPLICABLE06/10/2008
Marmur, EliIndividualIndirect Ownership InterestNOT APPLICABLE06/10/2008
Country Oaks Partners LLCOrganizationOperational/Managerial ControlNOT APPLICABLE11/05/2008
Country Oaks Partners LLCOrganizationADP of the SNFNOT APPLICABLE11/05/2008
Dehghanmanesh, AdrianIndividualOperational/Managerial ControlNOT APPLICABLE06/01/2021
Dehghanmanesh, AdrianIndividualADP of the SNFNOT APPLICABLE06/01/2021
Farrales, MaryIndividualADP of the SNFNOT APPLICABLE01/01/2023
Johnson, FrankIndividualManaging Control - Governing BodyNOT APPLICABLE06/10/2008
Johnson, FrankIndividualOperational/Managerial ControlNOT APPLICABLE06/10/2008
Kochek, JoshuaIndividualOperational/Managerial ControlNOT APPLICABLE04/01/2022
Kochek, JoshuaIndividualADP of the SNFNOT APPLICABLE04/01/2022
Manzon, EdwinIndividualOperational/Managerial ControlNOT APPLICABLE05/23/2024
Manzon, EdwinIndividualADP of the SNFNOT APPLICABLE05/23/2024
Oxford, MichealIndividualCorporate OfficerNOT APPLICABLE01/03/2022
Oxford, MichealIndividualOperational/Managerial ControlNOT APPLICABLE01/03/2022
Oxford, MichealIndividualADP of the SNFNOT APPLICABLE01/03/2022
Sandhu, GaryIndividualOperational/Managerial ControlNOT APPLICABLE01/01/2016

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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Claremont Manor Care Center2.5 miClaremont, CA★★★☆☆3/5
Chino Valley Health Care Cente2.6 miPomona, CA★★☆☆☆2/5abuse
Pilgrim Place Health Services Center2.6 miClaremont, CA★★★☆☆2/5
Claremont Care Center2.9 miPomona, CA★★★★☆3/5
Woods Health Services3.3 miLa Verne, CA★★★☆☆2/5

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Facility data as of CMS processing date 2026-08-01. CCN 055247.