California ›Santa Monica

Good Shepherd Health Care Center of Santa Monica

1131 Arizona Ave., Santa Monica, CA 90401 · Los Angeles County · 48 certified beds · avg 43 residents/day · certified since Mar 22, 1977

Part of chain: IL & JOAN LEE (4 facilities, chain avg rating 2.0★)

2/5
Health inspection rating (on-site)
1
Serious findings on record
$8,424
Fines, last 3 years
0.00
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: 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 · Dec 29, 2024 · F-0686 · triggered by a complaint

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.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

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 27, 2025 (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.

DateSeverityWhat the facility was cited for
Feb 25, 2026E · Potential for harm, repeatedThe 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.
Feb 25, 2026E · 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 25, 2026E · 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.
Feb 25, 2026E · 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 25, 2026E · 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.
Feb 25, 2026E · 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.
Feb 25, 2026D · 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 25, 2026D · Potential for harm, one-offThe facility did not honor residents' right to form and take part in resident or family groups, such as a resident council.
Feb 25, 2026D · Potential for harm, one-offThe facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids.
Feb 25, 2026D · Potential for harm, one-offThe 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 25, 2026D · Potential for harm, one-offThe 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.
Feb 25, 2026D · 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.
Feb 25, 2026D · 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.
Feb 25, 2026D · Potential for harm, one-offThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Feb 25, 2026D · Potential for harm, one-offThe facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.
Feb 25, 2026B · 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 29, 2024▲ G · Actual 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. · from a complaint
Dec 29, 2024F · Potential for harm, facility-wideThe facility did not have enough support staff to safely and effectively run its food and nutrition service.
Dec 29, 2024F · Potential for harm, facility-wideThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Dec 29, 2024F · Potential for harm, facility-wideThe 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 29, 2024F · Potential for harm, facility-wideThe facility did not dispose of garbage and refuse properly.
Dec 29, 2024F · Potential for harm, facility-wideThe facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records.
Dec 29, 2024E · Potential for harm, repeatedThe facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately.
Dec 29, 2024E · Potential for harm, repeatedThe facility did not provide safe and appropriate pain management for a resident who needed it.
Dec 29, 2024E · Potential for harm, repeatedThe 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.
Dec 29, 2024E · Potential for harm, repeatedThe facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems.
Dec 29, 2024E · Potential for harm, 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 29, 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.
Dec 29, 2024D · Potential for harm, one-offThe facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · from a complaint
Dec 29, 2024D · Potential for harm, one-offThe facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings.
Dec 29, 2024D · Potential for harm, one-offThe facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint
Dec 29, 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
Dec 29, 2024D · Potential for harm, one-offThe 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.
Dec 29, 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.
Dec 29, 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.
Dec 29, 2024D · Potential for harm, one-offThe facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service.
Dec 29, 2024D · Potential for harm, one-offThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Dec 7, 2023F · Potential for harm, facility-wideThe facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records.
Dec 7, 2023E · Potential for harm, repeatedThe facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing.
Dec 7, 2023E · Potential for harm, repeatedThe 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 7, 2023E · 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.
Dec 7, 2023E · Potential for harm, 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 7, 2023D · 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.
Dec 7, 2023D · Potential for harm, one-offThe facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out.
Dec 7, 2023D · Potential for harm, one-offThe facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way.
Dec 7, 2023D · Potential for harm, one-offThe facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services.
Dec 7, 2023D · Potential for harm, one-offThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Dec 7, 2023D · Potential for harm, one-offThe facility did not properly run its feeding assistant program — assessing which residents are appropriate for it, following each resident's care plan, and making sure feeding assistants are trained and supervised. Feeding assistants are trained helpers who assist residents at mealtimes.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (21 → 16).

YearCitationsSerious (G–L)Worst severity that year
2023110F
2024211G ▲
2026160E

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 $8,424.

DateTypeAmount / length
Dec 29, 2024Fine$8,424

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)0.004.313.95—
Registered Nurse hours0.000.610.69—
Weekend total nurse staffing0.003.903.50—
Weekend RN hours (not acuity-adjusted)0.000.510.48—
Total nursing staff turnover (%)0.036.745.8—
RN turnover (%)0.038.142.9—

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 0.00, RN 0.00, weekend 0.00. 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: 5/5 · long-stay residents: 4/5 · short-stay residents: 5/5

Who owns this facility

For profit - Corporation

Owner / managerTypeRoleStakeSince
Good Shepherd Health Care Center of Santa MonicaOrganizationDirect Ownership InterestNOT APPLICABLE01/01/1992
Lee, JoanIndividualDirect Ownership InterestNOT APPLICABLE02/07/1992
Good Shepherd Health Care Center of Santa MonicaOrganizationOperational/Managerial ControlNOT APPLICABLE01/01/1992
Good Shepherd Health Care Center of Santa MonicaOrganizationADP of the SNFNOT APPLICABLE02/10/2025
Hossain, SyedIndividualOperational/Managerial ControlNOT APPLICABLE01/01/2018
Hossain, SyedIndividualADP of the SNFNOT APPLICABLE01/01/2018
JPH Consulting INCOrganizationOperational/Managerial ControlNOT APPLICABLE02/10/1992
JPH Consulting INCOrganizationADP of the SNFNOT APPLICABLE12/31/2024
Lee, JoanIndividualCorporate OfficerNOT APPLICABLE02/07/1992
Morris, MonicaIndividualOperational/Managerial ControlNOT APPLICABLE01/01/2023
Morris, MonicaIndividualADP of the SNFNOT APPLICABLE01/01/2023

Questions to ask on your visit

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

Nearby facilities (within 20 miles)

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Brentwood Health Care Center1.6 miSanta Monica, CA★★★☆☆3/5
Sunset Park Healthcare1.7 miSanta Monica, CA★★☆☆☆2/5
Ocean Park Healthcare1.7 miSanta Monica, CA★★☆☆☆2/5
Westwood Post Acute Care2.1 miLos Angeles, CA★★☆☆☆2/5abuse

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Facility data as of CMS processing date 2026-08-01. CCN 555061.