California ›Fullerton

Gordon Lane Care Center

1821 E Chapman Ave, Fullerton, CA 92831 · Orange County · 99 certified beds · avg 94 residents/day · certified since Oct 18, 2002

Abuse citation flag (CMS)

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

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.

2/5
Health inspection rating (on-site)
0
Serious findings on record
$0
Fines, last 3 years
3.53
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.

All citations in the current public record (103)

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
Jun 23, 2026D · 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
Jun 23, 2026D · 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
Aug 4, 2025D · 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.
Aug 4, 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.
Aug 4, 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.
Aug 4, 2025D · Potential for harm, one-offThe 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.
Aug 4, 2025D · Potential for harm, one-offThe facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay).
Aug 4, 2025D · 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.
Aug 4, 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.
Aug 4, 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.
Aug 4, 2025D · 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.
Aug 4, 2025D · Potential for harm, one-offThe 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.
Aug 4, 2025D · Potential for harm, one-offThe facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them.
Aug 4, 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.
Aug 4, 2025D · Potential for harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it.
Aug 4, 2025D · 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.
Aug 4, 2025D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Aug 4, 2025D · Potential for harm, one-offThe 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.
Aug 4, 2025D · Potential for harm, one-offThe 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.
Aug 4, 2025D · Potential for harm, one-offThe facility did not have a policy covering how food brought in by family and visitors is used and stored safely.
Aug 4, 2025D · Potential for harm, one-offThe 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.
Aug 4, 2025D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Aug 4, 2025D · Potential for harm, one-offThe facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life.
Aug 4, 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
Aug 4, 2025D · Potential for harm, one-offThe facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. · from a complaint
Aug 4, 2025D · Potential for harm, one-offThe facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames.
Aug 4, 2025B · Minimal risk, repeatedThe 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.
Jun 18, 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
Jun 2, 2025D · Potential for harm, one-offThe 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
Jun 2, 2025D · Potential for harm, one-offThe 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
Feb 5, 2025B · Minimal risk, 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. · from a complaint
Nov 21, 2024B · Minimal risk, 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
Nov 21, 2024B · Minimal risk, 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. · from a complaint
Oct 2, 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
Oct 2, 2024D · Potential for harm, one-offThe 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
Oct 2, 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. · from a complaint
Sep 3, 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
Sep 3, 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
Sep 3, 2024B · Minimal risk, repeatedThe facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · from a complaint
Jun 26, 2024D · 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
Jun 26, 2024B · Minimal risk, 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. · from a complaint
Jun 26, 2024B · Minimal risk, repeatedThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Apr 12, 2024E · 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.
Apr 12, 2024E · 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.
Apr 12, 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.
Apr 12, 2024E · 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.
Apr 12, 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.
Apr 12, 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.
Apr 12, 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.
Apr 12, 2024D · Potential for harm, one-offThe 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.
Apr 12, 2024D · 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.
Apr 12, 2024D · 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.
Apr 12, 2024D · Potential for harm, one-offThe 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.
Apr 12, 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.
Apr 12, 2024D · Potential for harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it.
Apr 12, 2024D · 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.
Apr 12, 2024D · 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.
Apr 12, 2024D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Apr 12, 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.
Apr 12, 2024D · Potential for harm, one-offThe 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.
Apr 12, 2024D · 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.
Apr 12, 2024D · 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.
Apr 12, 2024D · Potential for harm, one-offThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Apr 12, 2024D · Potential for harm, one-offThe 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.
Apr 12, 2024D · Potential for harm, one-offThe facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives.
Apr 12, 2024D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Apr 12, 2024D · Potential for harm, one-offThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
Apr 12, 2024B · Minimal risk, repeatedThe 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.
Apr 12, 2024B · Minimal risk, repeatedThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly.
Dec 13, 2023D · 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. · from a complaint
Dec 13, 2023D · 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
Oct 24, 2023D · Potential for harm, one-offThe 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. · from a complaint
Oct 24, 2023D · Potential for harm, one-offThe facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. · from a complaint
Oct 24, 2023D · 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
Oct 2, 2023E · 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. · from a complaint
Aug 24, 2023D · Potential for harm, one-offThe 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
Aug 24, 2023D · 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
Aug 24, 2023D · 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
Aug 24, 2023D · Potential for harm, one-offThe 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
Aug 24, 2023D · Potential for harm, one-offThe 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. · from a complaint
Aug 24, 2023D · 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. · from a complaint
Aug 24, 2023D · Potential for harm, one-offThe 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. · from a complaint
Aug 24, 2023D · Potential for harm, one-offThe facility did not provide timely, quality laboratory tests to meet residents' needs. · from a complaint
Aug 24, 2023D · Potential for harm, one-offThe facility was not properly licensed, or did not operate in compliance with federal, state, and local laws, regulations, and accepted professional standards. · from a complaint
Aug 24, 2023D · 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
Aug 24, 2023D · 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
Aug 24, 2023B · Minimal risk, repeatedThe facility did not keep residents' personal and medical information private and confidential. · from a complaint
Aug 24, 2023B · Minimal risk, 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. · from a complaint
Aug 2, 2023E · 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. · from a complaint
Mar 18, 2022E · 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.
Mar 18, 2022E · 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.
Mar 18, 2022D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Mar 18, 2022D · 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.
Mar 18, 2022D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Mar 18, 2022D · 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 18, 2022D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Mar 18, 2022D · Potential for harm, one-offThe 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.
Mar 18, 2022D · 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 18, 2022D · Potential for harm, one-offThe 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.
Mar 18, 2022D · Potential for harm, one-offThe 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.
Mar 18, 2022D · 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.
Mar 18, 2022D · Potential for harm, one-offThe facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.
Mar 18, 2022D · Potential for harm, one-offThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (27 → 25).

YearCitationsSerious (G–L)Worst severity that year
2022140E
2023200E
2024380E
2025290D
202620D

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)3.534.313.95bottom 11% in California; bottom 38% in the U.S.
Registered Nurse hours0.290.610.69bottom 10% in California; bottom 8% in the U.S.
Weekend total nurse staffing3.253.903.50bottom 14% in California; bottom 44% in the U.S.
Weekend RN hours (not acuity-adjusted)0.200.510.48bottom 11% in California; bottom 12% in the U.S.
Total nursing staff turnover (%)26.036.745.8top 19% in California; top 8% in the U.S.
RN turnover (%)28.638.142.9top 33% in California; top 26% 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 4.14, RN 0.34, weekend 3.80. 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: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Gordon Lane Healthcare LLCOrganization5% or Greater Direct Ownership Interest100%10/12/2001
Dehghanmanesh, AdrianIndividualOperational/Managerial ControlNOT APPLICABLE06/01/2021
Dehghanmanesh, AdrianIndividualADP of the SNFNOT APPLICABLE06/01/2021
Farrales, MaryIndividualOperational/Managerial ControlNOT APPLICABLE01/01/2023
Farrales, MaryIndividualADP of the SNFNOT APPLICABLE01/01/2023
Fullerton California, LPOrganizationADP of the SNFNOT APPLICABLE02/11/2025
Gordon Lane Healthcare LLCOrganizationOperational/Managerial ControlNOT APPLICABLE11/30/2001
Gordon Lane Healthcare LLCOrganizationADP of the SNFNOT APPLICABLE11/30/2001
Hsieh, Pin HungIndividualOperational/Managerial ControlNOT APPLICABLE11/01/2014
Hsieh, Pin HungIndividualADP of the SNFNOT APPLICABLE11/01/2014
Iyer, SuchitraIndividualOperational/Managerial ControlNOT APPLICABLE09/01/2024
Iyer, SuchitraIndividualADP of the SNFNOT APPLICABLE09/01/2024
Johnson, FrankIndividualManaging Control - Governing BodyNOT APPLICABLE10/12/2001
Johnson, FrankIndividualOperational/Managerial ControlNOT APPLICABLE10/12/2001
Johnson, FrankIndividualADP of the SNFNOT APPLICABLE10/12/2001
Kochek, JoshuaIndividualOperational/Managerial ControlNOT APPLICABLE04/01/2022
Kochek, JoshuaIndividualADP of the SNFNOT APPLICABLE04/01/2022
Oxford, MichealIndividualOperational/Managerial ControlNOT APPLICABLE01/03/2022
Oxford, MichealIndividualADP of the SNFNOT APPLICABLE01/03/2022
Rivera, GraceIndividualADP of the SNFNOT APPLICABLE06/01/2012

Questions to ask on your visit

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

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Facility data as of CMS processing date 2026-08-01. CCN 555797.