Garden Crest Rehabilitation Center
909 Lucile Ave., Los Angeles, CA 90026 · Los Angeles County · 72 certified beds · avg 60 residents/day · certified since Jan 1, 1979
3/5
Health inspection rating (on-site)
2
Serious findings on record
$0
Fines, last 3 years
3.65
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: 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)
▲ Actual harm, one-off · Nov 16, 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 (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 12, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 23, 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 (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 14, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (48)
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 |
|---|---|---|
| May 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. · from a complaint |
| Jan 13, 2026 | 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 13, 2026 | 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 17, 2025 | 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 17, 2025 | E · Potential for harm, repeated | 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. |
| Dec 17, 2025 | E · Potential for harm, repeated | 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. |
| Dec 17, 2025 | 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 17, 2025 | B · Minimal risk, repeated | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. |
| Aug 28, 2025 | E · Potential for harm, repeated | The 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. · from a complaint |
| Aug 28, 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. · from a complaint |
| Aug 28, 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. · from a complaint |
| Aug 20, 2025 | 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. · from a complaint |
| May 28, 2025 | 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. · from a complaint |
| May 16, 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 |
| Feb 12, 2025 | D · Potential for harm, one-off | The facility did not protect residents from being involuntarily separated — kept apart from other residents, kept out of their own room, or confined to their room. Isolating a resident this way is a form of mistreatment. · from a complaint |
| Feb 3, 2025 | E · Potential for harm, repeated | 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. · from a complaint |
| Nov 15, 2024 | F · Potential for harm, facility-wide | The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. |
| Nov 15, 2024 | E · Potential for harm, repeated | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Nov 15, 2024 | 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. |
| Nov 15, 2024 | 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. |
| Nov 15, 2024 | 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. |
| Nov 15, 2024 | D · Potential for harm, one-off | The 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. |
| Nov 15, 2024 | 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. |
| Nov 15, 2024 | B · Minimal risk, repeated | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. |
| Sep 19, 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 |
| Sep 19, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Sep 19, 2024 | D · Potential for harm, one-off | The 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. · from a complaint |
| Jul 30, 2024 | E · Potential for harm, repeated | 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. · from a complaint |
| Jul 30, 2024 | 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. · from a complaint |
| Apr 23, 2024 | E · Potential for harm, repeated | The 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 |
| Apr 23, 2024 | 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. · from a complaint |
| Apr 9, 2024 | 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. · from a complaint |
| Jan 12, 2024 | E · Potential for harm, repeated | 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. · from a complaint |
| Nov 16, 2023 | ▲ G · Actual 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. · from a complaint |
| Nov 16, 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. |
| Nov 16, 2023 | E · Potential for harm, repeated | 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. |
| Nov 16, 2023 | E · Potential for harm, repeated | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. |
| Nov 16, 2023 | 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. |
| Nov 16, 2023 | 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. |
| Nov 16, 2023 | 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. |
| Nov 16, 2023 | D · Potential for harm, one-off | The 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. |
| Nov 16, 2023 | 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. |
| Nov 16, 2023 | D · Potential for harm, one-off | The 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. |
| Nov 16, 2023 | 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. |
| Sep 22, 2023 | D · Potential for harm, one-off | 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 |
| Aug 23, 2023 | ▲ G · Actual 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. · from a complaint |
| Aug 23, 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. · from a complaint |
| Aug 23, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (8 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 15 | 2 | G ▲ |
| 2024 | 17 | 0 | F |
| 2025 | 13 | 0 | E |
| 2026 | 3 | 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)
No fines or payment denials in the published 3-year window.
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) | 3.65 | 4.31 | 3.95 | bottom 18% in California; bottom 44% in the U.S. |
| Registered Nurse hours | 0.25 | 0.61 | 0.69 | bottom 5% in California; bottom 5% in the U.S. |
| Weekend total nurse staffing | 3.54 | 3.90 | 3.50 | bottom 34% in California; top 40% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.13 | 0.51 | 0.48 | bottom 1% in California; bottom 3% in the U.S. |
| Total nursing staff turnover (%) | 53.5 | 36.7 | 45.8 | bottom 9% in California; bottom 28% in the U.S. |
| RN turnover (%) | 71.4 | 38.1 | 42.9 | bottom 7% in California; bottom 11% 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 3.26, RN 0.23, weekend 3.16. Staffing rating: 1/5.
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 - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Barron, Paul | Individual | 5% or Greater Direct Ownership Interest | 100% | 05/30/1980 |
| Barron, Paul | Individual | W-2 Managing Employee | NOT APPLICABLE | 05/30/1980 |
| Barron, Paul | Individual | Corporate Director | NOT APPLICABLE | 05/30/1980 |
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?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "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 |
|---|---|---|---|---|---|
| Virgil Rehabilitation & Skilled Nursing Center | 0.7 mi | Los Angeles, CA | ★★★☆☆ | 2/5 | |
| Hollywood Presbyterian Medical Center D/P SNF | 0.9 mi | Los Angeles, CA | ★★★☆☆ | 3/5 | |
| Temple Park Convalescent Hospital | 1.1 mi | Los Angeles, CA | ★☆☆☆☆ | 2/5 | |
| The Meadows on Sunset Post Acute | 1.5 mi | Los Angeles, CA | ★☆☆☆☆ | 1/5 | |
| Alexandria Care Center | 1.5 mi | Los Angeles, CA | ★☆☆☆☆ | 1/5 | |
| The Rehabilitation Center of Los Angeles | 1.6 mi | Los Angeles, CA | ★☆☆☆☆ | 1/5 | |
| Westlake Convalescent Hospital | 1.6 mi | Los Angeles, CA | ★★★★☆ | 3/5 | |
| Bonnie Brae Skilled Nursing | 1.8 mi | Los Angeles, CA | ★★★★★ | 4/5 | |
| Los Feliz Healthcare & Wellness Center, LP | 1.8 mi | Los Angeles, CA | ★☆☆☆☆ | 1/5 | |
| Skyline Healthcare Center - la | 1.8 mi | Los Angeles, CA | ★☆☆☆☆ | 1/5 | SFF |
| Angels Nursing Health Center | 1.8 mi | Los Angeles, CA | ★★★★★ | 4/5 | |
| Palazzo Post Acute | 1.9 mi | Los Angeles, CA | ★★★★☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 055161.