Garden View Post Acute Rehabilitation

Name: Garden View Post Acute Rehabilitation
Address: 14475 GARDEN VIEW LANE, Baldwin Park, CA, 91706, US
Telephone: 6269627095

14475 Garden View Lane, Baldwin Park, CA 91706 · Los Angeles County · 97 certified beds · avg 90 residents/day · certified since Jun 1, 1972

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

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

4.04

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: 4/5

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 (45)

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 7, 2026	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
May 7, 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
Feb 27, 2026	E · Potential for harm, repeated	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 27, 2026	E · Potential for harm, repeated	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Feb 27, 2026	E · Potential for harm, repeated	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.
Feb 27, 2026	E · Potential for harm, repeated	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Feb 27, 2026	E · Potential for harm, repeated	The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Feb 27, 2026	E · Potential for harm, repeated	The facility did not provide routine dental care and 24-hour emergency dental care for residents.
Feb 27, 2026	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.
Feb 27, 2026	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Feb 27, 2026	D · Potential for harm, one-off	The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.
Feb 27, 2026	D · Potential for harm, one-off	The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function.
Feb 27, 2026	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.
Feb 27, 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 27, 2026	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.
Feb 27, 2026	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.
Feb 27, 2026	D · Potential for harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Feb 27, 2026	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.
Feb 27, 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.
Jan 10, 2025	E · Potential for harm, repeated	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.
Jan 10, 2025	E · Potential for harm, repeated	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.
Jan 10, 2025	E · Potential for harm, repeated	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.
Jan 10, 2025	E · Potential for harm, repeated	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.
Jan 10, 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.
Jan 10, 2025	D · Potential for harm, one-off	The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have.
Jan 10, 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.
Jan 10, 2025	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.
Jan 10, 2025	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.
Jan 10, 2025	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.
Jan 10, 2025	D · Potential for harm, one-off	The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Jan 10, 2025	B · Minimal risk, repeated	The 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.
Nov 25, 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
Nov 25, 2024	D · Potential for harm, one-off	The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. · from a complaint
Jan 5, 2024	E · Potential for harm, repeated	The 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.
Jan 5, 2024	E · Potential for harm, repeated	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.
Jan 5, 2024	E · Potential for harm, repeated	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jan 5, 2024	E · Potential for harm, repeated	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.
Jan 5, 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.
Jan 5, 2024	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.
Jan 5, 2024	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.
Jan 5, 2024	D · Potential for harm, one-off	The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have.
Jan 5, 2024	D · Potential for harm, one-off	The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids.
Jan 5, 2024	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.
Jan 5, 2024	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.
Dec 19, 2023	E · Potential for harm, repeated	The facility admitted a resident without a doctor's order, or did not make sure each resident stayed under a doctor's ongoing care. · from a complaint

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (12 → 17).

Year	Citations	Worst severity that year
2023	1	E
2024	13	E
2025	12	E
2026	19	E

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)	4.04	4.31	3.95	bottom 45% in California; top 38% in the U.S.
Registered Nurse hours	0.42	0.61	0.69	bottom 37% in California; bottom 25% in the U.S.
Weekend total nurse staffing	3.57	3.90	3.50	bottom 35% in California; top 39% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.32	0.51	0.48	bottom 38% in California; bottom 36% in the U.S.
Total nursing staff turnover (%)	39.6	36.7	45.8	bottom 39% in California; top 35% in the U.S.
RN turnover (%)	0.0	38.1	42.9	top 1% in California; top 1% 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 4.34, RN 0.45, weekend 3.83. 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: 5/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Burnam, Soon	Individual	Corporate Officer	NOT APPLICABLE	11/08/2022
Ensign Services INC	Organization	ADP of the SNF	NOT APPLICABLE	11/02/2022
Gamero, Alicia	Individual	Corporate Officer	NOT APPLICABLE	02/01/2023
Keetch, Chad	Individual	Corporate Officer	NOT APPLICABLE	03/01/2011
Leet, Ryan	Individual	Managing Control - Governing Body	NOT APPLICABLE	02/01/2023
Leet, Ryan	Individual	Operational/Managerial Control	NOT APPLICABLE	02/01/2023
Leet, Ryan	Individual	ADP of the SNF	NOT APPLICABLE	02/01/2023
Port, Barry	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	06/28/2025
Sato, Ami	Individual	Corporate Officer	NOT APPLICABLE	09/09/2024
Singh, Jhujhar	Individual	Managing Control - Governing Body	NOT APPLICABLE	02/01/2025
Singh, Jhujhar	Individual	Operational/Managerial Control	NOT APPLICABLE	02/01/2025
Singh, Jhujhar	Individual	ADP of the SNF	NOT APPLICABLE	02/01/2025
Willits, Adam	Individual	Corporate Director	NOT APPLICABLE	02/01/2023

Questions to ask on your visit

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

"Before a resident is discharged or transferred, how do you make sure the new place can actually meet their needs?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
"Who completes resident assessments here, and how do you check them for accuracy?"
"How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
"How do residents get routine dental care, and what happens if someone has a dental emergency at night?"
"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
West Covina Healthcare Center	0.6 mi	West Covina, CA	★★★☆☆	3/5
Victoria Care Center	0.8 mi	Baldwin Park, CA	★★★★★	4/5
Beacon Healthcare Center	1.1 mi	West Covina, CA	★★★★★	4/5
West Haven Healthcare	1.1 mi	West Covina, CA	★★★★☆	3/5
West Covina Medical Center D/P SNF	1.2 mi	West Covina, CA	★★★★☆	4/5
Coast Care Convalescent Center	1.6 mi	Baldwin Park, CA	★★★★☆	4/5
Clara Baldwin Stocker Home for Women	1.7 mi	West Covina, CA	★★★☆☆	2/5
Sierra View Care Center	1.8 mi	Baldwin Park, CA	★★★★☆	3/5
Eastland Subacute and Rehabilitation Center	2.9 mi	El Monte, CA	★★☆☆☆	2/5
Penn Mar Healthcare Center	2.9 mi	El Monte, CA	★★☆☆☆	2/5
El Encanto Healthcare Center	3.3 mi	City of Industry, CA	★★★★★	4/5
The Gardens of el Monte	3.3 mi	El Monte, CA	★★☆☆☆	2/5

Compare this facility with the 3 closest →

All facilities in Baldwin Park →

Facility data as of CMS processing date 2026-08-01. CCN 055187.

The Care File

Visit checklist — Garden View Post Acute Rehabilitation

14475 Garden View Lane, Baldwin Park, CA 91706 · 6269627095

Health inspection rating 3/5 · CMS overall 4/5· Fines (3y): $0

Questions for the administrator:

☐ "Before a resident is discharged or transferred, how do you make sure the new place can actually meet their needs?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
☐ "Who completes resident assessments here, and how do you check them for accuracy?"
☐ "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
☐ "How do residents get routine dental care, and what happens if someone has a dental emergency at night?"
☐ "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?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 055187 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)