Del Rosa Villa
2018 N Del Rosa Ave, San Bernardino, CA 92404 · San Bernardino County · 104 certified beds · avg 92 residents/day · certified since Sep 10, 1984
Abuse citation flag (CMS)
Part of chain: PACS GROUP (274 facilities, chain avg rating 2.9★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
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 · Nov 13, 2024 · 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: Nov 29, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (34)
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, carry out, or maintain an effective training program for all new and existing staff members. · from a complaint |
| Feb 12, 2026 | 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. |
| Feb 12, 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. |
| Feb 12, 2026 | D · Potential for harm, one-off | The 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. |
| Feb 12, 2026 | 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. |
| Feb 12, 2026 | 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. |
| Feb 12, 2026 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Feb 12, 2026 | 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. |
| Feb 12, 2026 | D · Potential for harm, one-off | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| Sep 10, 2025 | D · Potential for harm, one-off | The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint |
| Aug 13, 2025 | D · Potential for harm, one-off | The 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 |
| Mar 20, 2025 | D · Potential for harm, one-off | The 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 |
| Feb 27, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jan 24, 2025 | E · Potential for harm, repeated | 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. |
| Jan 24, 2025 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Jan 24, 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. |
| Jan 24, 2025 | 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. |
| Jan 24, 2025 | 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. |
| Nov 13, 2024 | ▲ 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 |
| Sep 26, 2024 | D · Potential for harm, one-off | The 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 |
| Sep 17, 2024 | 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. · from a complaint |
| Dec 13, 2023 | E · Potential for harm, repeated | The 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. |
| Dec 13, 2023 | D · Potential for harm, one-off | The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. |
| Dec 13, 2023 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Dec 13, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Dec 13, 2023 | 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. |
| Dec 13, 2023 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Dec 13, 2023 | D · Potential for harm, one-off | The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition. |
| Dec 13, 2023 | 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. |
| Dec 13, 2023 | D · Potential for harm, one-off | The facility did not notify the appropriate authorities when a resident with a mental disorder or intellectual disability had a significant change in condition. |
| Dec 13, 2023 | D · Potential for harm, one-off | 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. |
| Dec 13, 2023 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Dec 13, 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. |
| Dec 13, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (5 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 13 | 0 | E |
| 2024 | 3 | 1 | J ▲ |
| 2025 | 9 | 0 | E |
| 2026 | 9 | 0 | D |
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 $43,930.
| Date | Type | Amount / length |
|---|---|---|
| Nov 13, 2024 | Fine | $43,930 |
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) | 3.50 | 4.31 | 3.95 | bottom 10% in California; bottom 37% in the U.S. |
| Registered Nurse hours | 0.27 | 0.61 | 0.69 | bottom 7% in California; bottom 7% in the U.S. |
| Weekend total nurse staffing | 3.24 | 3.90 | 3.50 | bottom 13% in California; bottom 44% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.27 | 0.51 | 0.48 | bottom 26% in California; bottom 25% in the U.S. |
| Total nursing staff turnover (%) | 49.1 | 36.7 | 45.8 | bottom 16% in California; bottom 39% in the U.S. |
| RN turnover (%) | 33.3 | 38.1 | 42.9 | top 40% in California; top 33% 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 3.84, RN 0.30, weekend 3.55. 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: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Providence Group of Southern California LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 01/01/2015 |
| Apt, Frederick | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Eskander, Ashraf | Individual | Contracted Managing Employee | NOT APPLICABLE | 06/02/2018 |
| Hancock, Mark | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Jenkins, Nicoletta | Individual | W-2 Managing Employee | NOT APPLICABLE | 09/01/2023 |
| Jenkins, Nicoletta | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2023 |
| Jergensen, Joshua | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Mitchell, John | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
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?"
- "What training do new hires get before working with residents, and what ongoing training do all staff receive?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "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 |
|---|---|---|---|---|---|
| Haven Post Acute | 0.8 mi | San Bernardino, CA | ★★★★☆ | 4/5 | |
| Sierra Vista | 1.1 mi | Highland, CA | ★★★☆☆ | 2/5 | abuse |
| Waterman Canyon Post Acute | 1.7 mi | San Bernardino, CA | ★★★★☆ | 4/5 | |
| Valley Healthcare Center | 1.7 mi | San Bernardino, CA | ★★★★☆ | 3/5 | |
| Medical Center Convalescent Hospital | 1.8 mi | San Bernardino, CA | ★★★★☆ | 4/5 | |
| Arrowhead Springs Healthcare | 1.9 mi | San Bernardino, CA | ★★★★☆ | 4/5 | |
| Highland Palms Healthcare Center | 2.6 mi | Highland, CA | ★★★★☆ | 4/5 | |
| Arrowhead Healthcare Center, LLC | 3.3 mi | San Bernardino, CA | ★★★★☆ | 4/5 | |
| Community Convalescent Center of San Bernardino | 4.1 mi | San Bernardino, CA | ★★★★★ | 5/5 | |
| Community Hospital of San Bernardino DP SNF | 4.1 mi | San Bernardino, CA | ★★☆☆☆ | 3/5 | |
| Shandin Hills Behavior Therapy Center | 4.3 mi | San Bernardino, CA | ★★★★★ | 5/5 | |
| Totally Kids Rehabilitation Hospital - D/P SNF | 4.4 mi | Loma Linda, CA | ★★★★★ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 555195.