La Paloma Healthcare Center
3232 Thunder Drive, Oceanside, CA 92056 · San Diego County · 93 certified beds · avg 84 residents/day · certified since Jan 1, 1967
Part of chain: PACS GROUP (274 facilities, chain avg rating 2.9★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★★5/5 · CMS overall rating: 5/5
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 · Jul 9, 2021 · F-0689
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: Aug 16, 2021 (Deficient, Provider has date of correction)
All citations in the current public record (30)
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 |
|---|---|---|
| Apr 17, 2025 | 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. |
| Apr 17, 2025 | 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. |
| Apr 17, 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. |
| Apr 17, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Aug 17, 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. · from a complaint |
| Aug 1, 2023 | 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 |
| Jul 9, 2021 | ▲ 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. |
| Jul 9, 2021 | 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. |
| Jul 9, 2021 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Jul 9, 2021 | 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. |
| Jul 9, 2021 | 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. |
| Jul 9, 2021 | 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. |
| Jul 9, 2021 | D · Potential for harm, one-off | The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. |
| Jul 9, 2021 | 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. |
| Jul 9, 2021 | 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. |
| Jul 9, 2021 | 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. |
| Jul 9, 2021 | D · Potential for harm, one-off | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Jul 9, 2021 | 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. |
| Apr 26, 2019 | 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. |
| Apr 26, 2019 | E · Potential for harm, repeated | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Apr 26, 2019 | E · Potential for harm, repeated | The 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 26, 2019 | 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. |
| Apr 26, 2019 | 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. |
| Apr 26, 2019 | 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. |
| Apr 26, 2019 | D · Potential for harm, one-off | 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. |
| Apr 26, 2019 | 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. |
| Apr 26, 2019 | 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. |
| Apr 26, 2019 | D · Potential for harm, one-off | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| Apr 26, 2019 | D · Potential for harm, one-off | The facility did not have a policy covering how food brought in by family and visitors is used and stored safely. |
| Apr 26, 2019 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (12 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 12 | 0 | E |
| 2021 | 12 | 1 | G ▲ |
| 2023 | 2 | 0 | D |
| 2025 | 4 | 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) | 3.90 | 4.31 | 3.95 | bottom 34% in California; top 44% in the U.S. |
| Registered Nurse hours | 0.39 | 0.61 | 0.69 | bottom 30% in California; bottom 20% in the U.S. |
| Weekend total nurse staffing | 3.66 | 3.90 | 3.50 | bottom 43% in California; top 35% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.26 | 0.51 | 0.48 | bottom 23% in California; bottom 23% in the U.S. |
| Total nursing staff turnover (%) | 40.2 | 36.7 | 45.8 | bottom 37% in California; top 37% in the U.S. |
| RN turnover (%) | 44.4 | 38.1 | 42.9 | bottom 36% in California; bottom 45% 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 3.95, RN 0.39, weekend 3.71. 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 |
|---|---|---|---|---|
| Apt, Frederick | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Duerden, Jonathan | Individual | W-2 Managing Employee | NOT APPLICABLE | 10/02/2023 |
| Hancock, Mark | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Jergensen, Joshua | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Mitchell, John | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Novak, Loren | Individual | Contracted Managing Employee | NOT APPLICABLE | 09/01/2021 |
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?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
- "What percentage of your residents and staff are vaccinated against flu and pneumonia, and how do you offer the vaccines?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "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 |
|---|---|---|---|---|---|
| Pacific Villas Post Acute | 0.0 mi | Oceanside, CA | —/5 | ||
| Vista Knoll Specialized Care Facility | 0.7 mi | Vista, CA | ★★★★★ | 4/5 | |
| Vista View Post Acute | 1.9 mi | Vista, CA | ★★★★☆ | 3/5 | |
| Bayshire Carlsbad | 2.0 mi | Carlsbad, CA | ★★★★☆ | 4/5 | |
| Santa Fe Post-Acute | 3.7 mi | Vista, CA | ★★☆☆☆ | 2/5 | |
| Carlsbad by the Sea | 4.0 mi | Carlsbad, CA | ★★★★★ | 5/5 | |
| Village Square Healthcare Center | 6.5 mi | San Marcos, CA | ★★★★☆ | 4/5 | |
| Glenbrook | 8.1 mi | Carlsbad, CA | ★★★★★ | 4/5 | |
| The Dorothy & Joseph Goldberg Healthcare Center | 9.4 mi | Encinitas, CA | ★★★★★ | 4/5 | |
| Aviara Healthcare Center | 10.2 mi | Encinitas, CA | ★★★★☆ | 3/5 | |
| Encinitas Post-Acute | 10.5 mi | Encinitas, CA | ★★★★☆ | 4/5 | |
| Meadowbrook Village Christian Retirement Community | 11.8 mi | Escondido, CA | ★★★★★ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 055335.