Hollenbeck Palms
573 S. Boyle Ave., Los Angeles, CA 90033 · Los Angeles County · 106 certified beds · avg 54 residents/day · certified since Jan 1, 1967
3/5
Health inspection rating (on-site)
2
Serious findings on record
$0
Fines, last 3 years
4.91
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.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jun 11, 2026 · 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: Jul 6, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 20, 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 (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 13, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (39)
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 11, 2026 | ▲ 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 |
| Jun 11, 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 |
| Feb 24, 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 |
| Jan 28, 2026 | D · Potential for harm, one-off | The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows. · from a complaint |
| Dec 12, 2025 | 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. |
| Dec 12, 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 12, 2025 | E · Potential for harm, repeated | The 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. |
| Dec 12, 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. |
| Dec 12, 2025 | 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. |
| Dec 12, 2025 | 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. |
| Dec 12, 2025 | 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. |
| Dec 12, 2025 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. |
| Dec 12, 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. |
| Oct 25, 2024 | F · Potential for harm, facility-wide | 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. |
| Oct 25, 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. |
| Oct 25, 2024 | 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. |
| Oct 25, 2024 | 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. |
| Oct 25, 2024 | E · Potential for harm, repeated | The facility did not dispose of garbage and refuse properly. |
| Oct 25, 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. |
| Oct 25, 2024 | D · Potential for harm, one-off | 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. |
| Oct 25, 2024 | 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. |
| Oct 25, 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. |
| Oct 25, 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. |
| Oct 25, 2024 | 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. |
| Oct 25, 2024 | 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. |
| Oct 25, 2024 | 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. |
| Aug 20, 2024 | ▲ 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 20, 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. · from a complaint |
| Aug 20, 2024 | 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. · from a complaint |
| Aug 20, 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 19, 2023 | 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. |
| Nov 19, 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 19, 2023 | E · Potential for harm, repeated | The 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. |
| Nov 19, 2023 | 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. |
| Nov 19, 2023 | D · Potential for harm, one-off | 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. |
| Nov 19, 2023 | 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. |
| Nov 19, 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. · from a complaint |
| Nov 19, 2023 | 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 19, 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. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (13 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 9 | 0 | E |
| 2024 | 17 | 1 | G ▲ |
| 2025 | 9 | 0 | E |
| 2026 | 4 | 1 | G ▲ |
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) | 4.91 | 4.31 | 3.95 | top 16% in California; top 15% in the U.S. |
| Registered Nurse hours | 0.82 | 0.61 | 0.69 | top 16% in California; top 26% in the U.S. |
| Weekend total nurse staffing | 4.48 | 3.90 | 3.50 | top 15% in California; top 12% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.53 | 0.51 | 0.48 | top 29% in California; top 30% in the U.S. |
| Total nursing staff turnover (%) | 28.1 | 36.7 | 45.8 | top 24% in California; top 11% in the U.S. |
| RN turnover (%) | 30.0 | 38.1 | 42.9 | top 38% in California; top 29% 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 4.59, RN 0.77, weekend 4.18. Staffing rating: 5/5.
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: 3/5 · long-stay residents: 2/5 · short-stay residents: 4/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Belle Home Care INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 09/01/2021 |
| Belle Home Care INC | Organization | ADP of the SNF | NOT APPLICABLE | 08/20/2025 |
| Johnston, Carol | Individual | Corporate Director | NOT APPLICABLE | 07/01/2013 |
| Johnston, Carol | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2013 |
| Johnston, Carol | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2013 |
| Kanegae, Thomas | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/02/2009 |
| Kanegae, Thomas | Individual | ADP of the SNF | NOT APPLICABLE | 12/02/2009 |
| Kirchhoff, Katherine | Individual | Corporate Director | NOT APPLICABLE | 07/01/2024 |
| Kirchhoff, Katherine | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Kirchhoff, Katherine | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Kumagai, William | Individual | Corporate Director | NOT APPLICABLE | 07/01/2024 |
| Kumagai, William | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Kumagai, William | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Onishi, Kevin | Individual | Corporate Director | NOT APPLICABLE | 07/01/2024 |
| Onishi, Kevin | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Onishi, Kevin | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2024 |
| Ramirez, Ivania | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/04/2021 |
| Ramirez, Ivania | Individual | ADP of the SNF | NOT APPLICABLE | 06/04/2021 |
| Rosenbloom, Linda | Individual | Corporate Director | NOT APPLICABLE | 07/01/2024 |
| Rosenbloom, Linda | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
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?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Who oversees residents' therapeutic diets, and how do the doctor and dietitian work together on them?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can you show me the call buttons in the bathrooms and bathing areas, and tell me your average response time when one is pressed?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "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 |
|---|---|---|---|---|---|
| Infinity Care of East Los Angeles | 0.6 mi | Los Angeles, CA | ★★☆☆☆ | 1/5 | abuse |
| White Memorial Medical Ctr DP | 0.8 mi | Los Angeles, CA | ★★★☆☆ | 4/5 | |
| Los Angeles Comm Hospital | 2.2 mi | Los Angeles, CA | ★★★★☆ | 4/5 | |
| Kei-Ai Los Angeles Healthcare Center | 2.5 mi | Los Angeles, CA | ★☆☆☆☆ | 1/5 | abuse |
| East Los Angeles Doctors Hosp | 2.5 mi | Los Angeles, CA | ★★★★★ | 5/5 | |
| Costa Del Sol Healthcare | 2.6 mi | Los Angeles, CA | ★★☆☆☆ | 2/5 | |
| Burlington Convalescent Hospital | 3.0 mi | Los Angeles, CA | ★★★★☆ | 4/5 | |
| Pih Health Good Samaritan Hospital D/P SNF | 3.0 mi | Los Angeles, CA | ★★★★★ | 5/5 | |
| University Park Healthcare Center | 3.0 mi | Los Angeles, CA | ★☆☆☆☆ | 1/5 | abuse |
| Maple Healthcare Center | 3.1 mi | Los Angeles, CA | ★☆☆☆☆ | 1/5 | abuse |
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Facility data as of CMS processing date 2026-08-01. CCN 055115.