California ›Lynwood

Lynwood Post Acute Care Center

3611 East Imperial Highway, Lynwood, CA 90262 · Los Angeles County · 99 certified beds · avg 90 residents/day · certified since Nov 27, 1973

Part of chain: CAMBRIDGE HEALTHCARE SERVICES (32 facilities, chain avg rating 2.5★)

2/5
Health inspection rating (on-site)
0
Serious findings on record
$0
Fines, last 3 years
3.92
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 (74)

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 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. · from a complaint
Jun 23, 2026D · 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 15, 2026D · Potential for harm, one-offThe facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint
Jun 15, 2026D · 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
Jun 2, 2026D · 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. · from a complaint
Apr 23, 2026E · Potential for harm, repeatedThe facility's bedrooms did not give residents visual privacy — such as curtains or dividers — when privacy is needed.
Apr 23, 2026D · 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.
Apr 23, 2026D · Potential for harm, one-offThe facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.
Apr 23, 2026D · 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.
Apr 23, 2026D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Apr 23, 2026D · 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 23, 2026D · Potential for harm, one-offThe 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.
Apr 23, 2026D · 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.
Apr 23, 2026D · 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.
Apr 23, 2026D · 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 23, 2026D · 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.
Apr 23, 2026D · 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 23, 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.
Apr 23, 2026D · Potential for harm, one-offThe facility did not dispose of garbage and refuse properly.
Apr 23, 2026D · 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 23, 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.
Apr 23, 2026D · Potential for harm, one-offThe 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 23, 2026D · Potential for harm, one-offThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Apr 23, 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.
Mar 31, 2026D · 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. · from a complaint
Mar 18, 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
Mar 18, 2026D · 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
Mar 18, 2026D · 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
Feb 22, 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. · from a complaint
Jan 13, 2026D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Jul 9, 2025D · Potential for harm, one-offThe facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint
Jul 9, 2025D · 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
Jul 9, 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
Jan 16, 2025E · 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.
Jan 16, 2025E · Potential for harm, repeatedThe 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 16, 2025E · 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.
Jan 16, 2025E · 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.
Jan 16, 2025D · 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.
Jan 16, 2025D · 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.
Jan 16, 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.
Jan 16, 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.
Jan 16, 2025D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jan 16, 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.
Jan 16, 2025D · Potential for harm, one-offThe 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.
Jan 16, 2025D · Potential for harm, one-offThe 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 16, 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.
Jan 16, 2025D · 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.
Jan 16, 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.
Jan 16, 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.
Nov 27, 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. · from a complaint
Jul 23, 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
Jan 25, 2024F · Potential for harm, facility-wideThe 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.
Jan 25, 2024E · Potential for harm, repeatedThe facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Jan 25, 2024E · 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.
Jan 25, 2024E · Potential for harm, repeatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Jan 25, 2024D · Potential for harm, one-offThe facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time.
Jan 25, 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.
Jan 25, 2024D · 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.
Jan 25, 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.
Jan 25, 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.
Jan 25, 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.
Jan 25, 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.
Jan 25, 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.
Jan 25, 2024D · 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.
Jan 25, 2024D · Potential for harm, one-offThe facility did not properly inform residents or their representatives about arbitration agreements — contracts that give up the right to sue in court — including their right to refuse to sign.
Jan 25, 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.
Jan 18, 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. · from a complaint
Nov 22, 2023E · 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. · from a complaint
Oct 17, 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
Sep 11, 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
Sep 5, 2023D · 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 24, 2023E · Potential for harm, repeatedThe facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program.
Aug 24, 2023D · Potential for harm, one-offThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Aug 18, 2023E · 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. · from a complaint

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (16 → 19).

YearCitationsSerious (G–L)Worst severity that year
202370E
2024180F
2025190E
2026300E

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)3.924.313.95bottom 36% in California; top 43% in the U.S.
Registered Nurse hours0.410.610.69bottom 36% in California; bottom 24% in the U.S.
Weekend total nurse staffing3.623.903.50bottom 40% in California; top 37% in the U.S.
Weekend RN hours (not acuity-adjusted)0.290.510.48bottom 31% in California; bottom 29% in the U.S.
Total nursing staff turnover (%)39.836.745.8bottom 39% in California; top 36% in the U.S.
RN turnover (%)62.538.142.9bottom 13% in California; bottom 19% 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 0.42, weekend 3.64. 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: 3/5 · long-stay residents: 5/5 · short-stay residents: 1/5

Who owns this facility

For profit - Corporation

Owner / managerTypeRoleStakeSince
Ag Facilities Operations, LLCOrganization5% or Greater Direct Ownership Interest100%08/11/2003
Ira E Smedra Living TrustOrganization5% or Greater Indirect Ownership Interest48%08/11/2003
Win Win Enterprises, LLCOrganization5% or Greater Indirect Ownership Interest48%08/11/2003
3611 E. Imperial, LLCOrganizationADP of the SNFNOT APPLICABLE09/15/2004
Butenko, JulieIndividualOperational/Managerial ControlNOT APPLICABLE07/24/2023
Butenko, JulieIndividualADP of the SNFNOT APPLICABLE07/24/2023
Cambridge Healthcare Services LLCOrganizationOperational/Managerial ControlNOT APPLICABLE10/01/2013
Cambridge Healthcare Services LLCOrganizationADP of the SNFNOT APPLICABLE07/17/2025
Capela, HeidiIndividualOperational/Managerial ControlNOT APPLICABLE04/03/2023
Capela, HeidiIndividualADP of the SNFNOT APPLICABLE04/03/2023
Hassell, LanceIndividualOperational/Managerial ControlNOT APPLICABLE04/25/2022
Hassell, LanceIndividualADP of the SNFNOT APPLICABLE04/25/2022
Kuizon, KristinaIndividualManaging Control - Governing BodyNOT APPLICABLE04/01/2025
Kuizon, KristinaIndividualOperational/Managerial ControlNOT APPLICABLE04/01/2025
Kuizon, KristinaIndividualADP of the SNFNOT APPLICABLE04/01/2025
Lutz, LindaIndividualOperational/Managerial ControlNOT APPLICABLE02/01/2012
Lutz, LindaIndividualADP of the SNFNOT APPLICABLE02/01/2012
Pease, AllisonIndividualManaging Control - Governing BodyNOT APPLICABLE03/28/2023
Pease, AllisonIndividualOperational/Managerial ControlNOT APPLICABLE03/28/2023
Pease, AllisonIndividualADP of the SNFNOT APPLICABLE07/17/2025

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)

FacilityDistanceCityOverallInspectionFlags
California Post-Acute Care0.0 miLynwood, CA★☆☆☆☆1/5abuseSFF
Granada Post Acute0.0 miLynwood, CA★★★☆☆3/5
Downey Post Acute1.4 miDowney, CA★★★★☆3/5
Briarcrest Nursing Center2.2 miBell Gardens, CA★☆☆☆☆1/5
Paramount Convalescent Hosp.2.5 miParamount, CA★★★☆☆2/5
Santa Fe Heights Healthcare Center, LLC2.6 miCompton, CA★☆☆☆☆1/5abuse
Greenfield Care Center of South Gate2.6 miSouth Gate, CA★☆☆☆☆1/5
Bell Convalescent Hospital2.7 miBell, CA★☆☆☆☆1/5
Meadow Creek Post-Acute2.9 miParamount, CA★☆☆☆☆1/5
Lakewood Healthcare Center2.9 miDowney, CA★☆☆☆☆1/5abuseSFF
Lighthouse Healthcare Center2.9 miLos Angeles, CA★☆☆☆☆1/5
Downey Community Health Center2.9 miDowney, CA★★☆☆☆2/5

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Facility data as of CMS processing date 2026-08-01. CCN 056415.