Magnolia Post Acute Care
635 S Magnolia Ave, El Cajon, CA 92020 · San Diego County · 99 certified beds · avg 95 residents/day · certified since Mar 11, 1968
Abuse citation flag (CMS)
Part of chain: THE ENSIGN GROUP (342 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)
1
Serious findings on record
$117,475
Fines, last 3 years
4.28
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: 3/5
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, repeated · Dec 11, 2025 · F-0600 · triggered by a complaint
The 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.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Jan 4, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (33)
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 |
|---|---|---|
| Dec 11, 2025 | ▲ H · Actual harm, repeated | The 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 |
| Dec 11, 2025 | D · Potential for harm, one-off | The 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. · from a complaint |
| Dec 11, 2025 | 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. · from a complaint |
| Dec 11, 2025 | 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 |
| Aug 29, 2025 | E · Potential for harm, repeated | 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. |
| Aug 29, 2025 | E · Potential for harm, repeated | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| Aug 29, 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. |
| Aug 29, 2025 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Aug 29, 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. |
| Aug 29, 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. |
| Aug 29, 2025 | 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. |
| Aug 29, 2025 | 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. |
| Aug 29, 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. |
| May 22, 2025 | D · Potential for harm, one-off | The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint |
| Apr 30, 2025 | D · Potential for harm, one-off | The 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 |
| Jun 13, 2024 | D · Potential for harm, one-off | The 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. |
| Jun 13, 2024 | 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. |
| Jun 13, 2024 | D · Potential for harm, one-off | The 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. |
| Jun 13, 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. |
| May 24, 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. · from a complaint |
| May 6, 2024 | 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. · from a complaint |
| Feb 16, 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 |
| Aug 17, 2023 | D · Potential for harm, one-off | The 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 |
| Jul 15, 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 15, 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 15, 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 15, 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 15, 2021 | D · Potential for harm, one-off | The 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. |
| Jul 15, 2021 | 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. |
| Jul 15, 2021 | 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. |
| Jul 15, 2021 | 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. |
| Jul 15, 2021 | 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. |
| Jul 15, 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. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (4 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 10 | 0 | E |
| 2023 | 1 | 0 | D |
| 2024 | 7 | 0 | D |
| 2025 | 15 | 1 | H ▲ |
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 $117,475.
| Date | Type | Amount / length |
|---|---|---|
| Dec 11, 2025 | Fine | $117,475 |
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) | 4.28 | 4.31 | 3.95 | top 39% in California; top 30% in the U.S. |
| Registered Nurse hours | 0.53 | 0.61 | 0.69 | top 42% in California; bottom 42% in the U.S. |
| Weekend total nurse staffing | 3.71 | 3.90 | 3.50 | bottom 47% in California; top 33% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.34 | 0.51 | 0.48 | bottom 43% in California; bottom 40% in the U.S. |
| Total nursing staff turnover (%) | 37.5 | 36.7 | 45.8 | bottom 46% in California; top 30% in the U.S. |
| RN turnover (%) | 50.0 | 38.1 | 42.9 | bottom 29% in California; bottom 39% 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 3.89, RN 0.48, weekend 3.37. Staffing rating: 4/5.
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: 4/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 09/10/2014 |
| Circle Health Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2022 |
| Dignified Staffing Registry INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/01/2014 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2014 |
| Jalil, Anmar | Individual | Managing Control - Governing Body | NOT APPLICABLE | 12/05/2017 |
| Jalil, Anmar | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/05/2017 |
| Jalil, Anmar | Individual | ADP of the SNF | NOT APPLICABLE | 12/05/2017 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 12/01/2014 |
| Port, Barry | Individual | Corporate Officer | NOT APPLICABLE | 12/01/2014 |
| Standard Bearer Healthcare Op, LP | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2022 |
| The Ensign Group INC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2022 |
| Williams, Michael | Individual | Managing Control - Governing Body | NOT APPLICABLE | 12/01/2014 |
| Williams, Michael | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2014 |
| Williams, Michael | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2014 |
| Willits, Adam | Individual | Corporate Officer | NOT APPLICABLE | 12/31/2021 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "How is your kitchen staffed, and have meals ever been delayed because of staffing?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "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 |
|---|---|---|---|---|---|
| Stillwater Post-Acute | 0.0 mi | El Cajon, CA | ★★☆☆☆ | 2/5 | |
| Somerset Post Acute Care | 0.4 mi | El Cajon, CA | ★★★☆☆ | 3/5 | |
| Victoria Post Acute Care | 0.6 mi | El Cajon, CA | ★★★★★ | 4/5 | |
| Villa Las Palmas Healthcare Center | 0.6 mi | El Cajon, CA | ★★★☆☆ | 3/5 | |
| San Diego Post-Acute Center | 0.6 mi | El Cajon, CA | ★☆☆☆☆ | 1/5 | abuse |
| Parkside Health and Wellness Center | 0.7 mi | El Cajon, CA | ★★★★★ | 5/5 | |
| Cottonwood Canyon Healthcare Center | 1.9 mi | El Cajon, CA | ★★★☆☆ | 2/5 | |
| Granite Hills Healthcare & Wellness Centre, LLC | 1.9 mi | El Cajon, CA | ★★☆☆☆ | 2/5 | |
| Bradley Court | 2.2 mi | El Cajon, CA | ★★★★★ | 5/5 | |
| Country Hills Post Acute | 2.7 mi | El Cajon, CA | ★☆☆☆☆ | 1/5 | |
| Grossmont Post Acute Care | 2.9 mi | La Mesa, CA | ★★★★☆ | 4/5 | |
| Grossmont Hospital D/P SNF | 3.0 mi | La Mesa, CA | ★★★★★ | 5/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 055890.