California ›Monrovia

Monrovia Gardens Healthcare Center

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615 W. Duarte Rd., Monrovia, CA 91016 (opens Google Maps) · Los Angeles County · (626) 358-4547· 96 certified beds · avg 80 residents/day · certified since Dec 31, 1971 · Medicare and Medicaid certified

Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →

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

1/5
Health inspection rating (on-site)
inspected Dec 19, 2025
1
Serious findings on record
most recent Jan 24, 2025
$0
Fines, last 3 years
3.99
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

New to these records? How to read an inspection report →

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5 · how star ratings work →

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 quality measures from resident assessments and claims.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, isolated · Jan 24, 2025 · 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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Feb 20, 2025 (Deficient, Provider has date of correction)

Inspection findings in the public record

Showing the latest 3 of 100 inspection findings. Open the full record below to read every finding.

  1. E · Potential for more than minimal harm, pattern

    The 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 F-0757

  2. D · Potential for more than minimal harm, isolated

    The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · from a complaint F-0552

  3. D · Potential for more than minimal harm, isolated

    The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · from a complaint F-0676

View all 100 inspection findingsShow only the latest 3 findings

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.

DateSeverityWhat the facility was cited for
Jun 23, 2026E · Potential for more than minimal harm, patternThe 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 · F-0757
Jun 23, 2026D · Potential for more than minimal harm, isolatedThe facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · from a complaint · F-0552
Jun 4, 2026D · Potential for more than minimal harm, isolatedThe facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · from a complaint · F-0676
Mar 3, 2026E · Potential for more than minimal harm, patternThe 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 · F-0657
Mar 3, 2026D · Potential for more than minimal harm, isolatedThe facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. · from a complaint · F-0687
Mar 3, 2026D · Potential for more than minimal harm, isolatedThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · from a complaint · F-0698
Dec 19, 2025E · Potential for more than minimal harm, patternThe 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. · F-0578
Dec 19, 2025E · Potential for more than minimal harm, patternThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684
Dec 19, 2025E · Potential for more than minimal harm, patternThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · F-0755
Dec 19, 2025E · Potential for more than minimal harm, patternThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812
Dec 19, 2025D · Potential for more than minimal harm, isolatedThe 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. · F-0550
Dec 19, 2025D · Potential for more than minimal harm, isolatedThe facility hired someone with an official finding of abuse, neglect, exploitation, or theft against them. Facilities are not allowed to employ people with such findings. · F-0606
Dec 19, 2025D · Potential for more than minimal harm, isolatedThe 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. · F-0656
Dec 19, 2025D · Potential for more than minimal harm, isolatedThe 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. · F-0657
Dec 19, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. · F-0679
Dec 19, 2025D · Potential for more than minimal harm, isolatedThe 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. · F-0686
Dec 19, 2025D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689
Dec 19, 2025D · Potential for more than minimal harm, isolatedThe 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. · F-0693
Dec 19, 2025D · Potential for more than minimal harm, isolatedThe 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. · F-0695
Dec 19, 2025D · Potential for more than minimal harm, isolatedThe 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. · F-0880
Dec 19, 2025D · Potential for more than minimal harm, isolatedThe 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. · F-0881
Oct 31, 2025D · Potential for more than minimal harm, isolatedThe 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 · F-0609
Sep 17, 2025D · Potential for more than minimal harm, isolatedThe facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · from a complaint · F-0557
Sep 3, 2025E · Potential for more than minimal harm, patternThe 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. · from a complaint · F-0677
Sep 3, 2025D · Potential for more than minimal harm, isolatedThe 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. · from a complaint · F-0558
Sep 3, 2025D · Potential for more than minimal harm, isolatedThe 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 · F-0808
Aug 27, 2025E · Potential for more than minimal harm, patternThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. · from a complaint · F-0908
Aug 5, 2025E · Potential for more than minimal harm, patternThe 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. · from a complaint · F-0558
Aug 5, 2025E · Potential for more than minimal harm, patternThe 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. · from a complaint · F-0677
Aug 5, 2025E · Potential for more than minimal harm, patternThe facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · from a complaint · F-0867
Jul 9, 2025D · Potential for more than minimal harm, isolatedThe 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. · from a complaint · F-0558
Jul 9, 2025D · Potential for more than minimal harm, isolatedThe facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint · F-0604
Jul 9, 2025D · Potential for more than minimal harm, isolatedThe 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 · F-0684
May 13, 2025D · Potential for more than minimal harm, isolatedThe 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. · from a complaint · F-0558
May 13, 2025D · Potential for more than minimal harm, isolatedThe 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 · F-0607
May 13, 2025D · Potential for more than minimal harm, isolatedThe 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. · from a complaint · F-0677
Apr 24, 2025E · Potential for more than minimal harm, patternThe 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 · F-0880
Apr 24, 2025D · Potential for more than minimal harm, isolatedThe 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 · F-0656
Mar 27, 2025E · Potential for more than minimal harm, patternThe 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. · from a complaint · F-0725
Mar 27, 2025D · Potential for more than minimal harm, isolatedThe facility did not keep residents' personal and medical information private and confidential. · from a complaint · F-0583
Mar 27, 2025D · Potential for more than minimal harm, isolatedThe 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. · from a complaint · F-0677
Mar 27, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint · F-0697
Mar 27, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint · F-0806
Mar 27, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide residents with enough to drink, or with drinks matching their needs and preferences, to keep them properly hydrated. · from a complaint · F-0807
Feb 26, 2025E · Potential for more than minimal harm, patternThe 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. · from a complaint · F-0688
Feb 26, 2025E · Potential for more than minimal harm, patternThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint · F-0842
Feb 26, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint · F-0584
Feb 10, 2025D · Potential for more than minimal harm, isolatedThe 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 · F-0656
Jan 24, 2025▲ G · Actual harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Jan 24, 2025E · Potential for more than minimal harm, patternThe 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. · from a complaint · F-0677
Jan 24, 2025E · Potential for more than minimal harm, patternThe 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. · from a complaint · F-0725
Jan 24, 2025D · Potential for more than minimal harm, isolatedThe facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. · from a complaint · F-0576
Jan 24, 2025D · Potential for more than minimal harm, isolatedThe 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 · F-0656
Jan 24, 2025D · Potential for more than minimal harm, isolatedThe 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 · F-0684
Jan 24, 2025D · Potential for more than minimal harm, isolatedThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint · F-0726
Dec 31, 2024E · Potential for more than minimal harm, patternThe 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. · from a complaint · F-0725
Dec 24, 2024D · Potential for more than minimal harm, isolatedThe 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 · F-0550
Dec 24, 2024D · Potential for more than minimal harm, isolatedThe 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 · F-0684
Nov 25, 2024D · Potential for more than minimal harm, isolatedThe 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 · F-0610
Oct 31, 2024E · Potential for more than minimal harm, patternThe 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. · F-0558
Oct 31, 2024E · Potential for more than minimal harm, patternThe 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. · F-0578
Oct 31, 2024E · Potential for more than minimal harm, patternThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684
Oct 31, 2024E · Potential for more than minimal harm, patternThe 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. · F-0686
Oct 31, 2024E · Potential for more than minimal harm, patternThe 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. · F-0690
Oct 31, 2024E · Potential for more than minimal harm, patternThe 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. · F-0725
Oct 31, 2024E · Potential for more than minimal harm, patternThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812
Oct 31, 2024E · Potential for more than minimal harm, patternThe 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. · F-0880
Oct 31, 2024D · Potential for more than minimal harm, isolatedThe 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. · F-0550
Oct 31, 2024D · Potential for more than minimal harm, isolatedThe 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. · F-0580
Oct 31, 2024D · Potential for more than minimal harm, isolatedThe 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. · F-0625
Oct 31, 2024D · Potential for more than minimal harm, isolatedThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · F-0641
Oct 31, 2024D · Potential for more than minimal harm, isolatedThe 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. · F-0656
Oct 31, 2024D · Potential for more than minimal harm, isolatedThe facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · F-0676
Oct 31, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · F-0692
Oct 31, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide routine dental care and 24-hour emergency dental care for residents. · F-0790
Oct 31, 2024D · Potential for more than minimal harm, isolatedThe 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. · F-0803
Oct 31, 2024D · Potential for more than minimal harm, isolatedThe 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. · F-0919
Jun 21, 2024D · Potential for more than minimal harm, isolatedThe 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 · F-0600
May 29, 2024D · Potential for more than minimal harm, isolatedThe 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 · F-0580
May 9, 2024E · Potential for more than minimal harm, patternThe facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. · from a complaint · F-0882
May 9, 2024D · Potential for more than minimal harm, isolatedThe 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. · from a complaint · F-0688
May 9, 2024D · Potential for more than minimal harm, isolatedThe 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 · F-0880
Oct 19, 2023E · Potential for more than minimal harm, patternThe 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. · F-0761
Oct 19, 2023E · Potential for more than minimal harm, patternThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812
Oct 19, 2023E · Potential for more than minimal harm, patternThe 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. · F-0880
Oct 19, 2023D · Potential for more than minimal harm, isolatedThe 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 · F-0550
Oct 19, 2023D · Potential for more than minimal harm, isolatedThe 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. · F-0645
Oct 19, 2023D · Potential for more than minimal harm, isolatedThe 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. · F-0656
Oct 19, 2023D · Potential for more than minimal harm, isolatedThe 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. · F-0657
Oct 19, 2023D · Potential for more than minimal harm, isolatedThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · F-0658
Oct 19, 2023D · Potential for more than minimal harm, isolatedThe facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. · F-0685
Oct 19, 2023D · Potential for more than minimal harm, isolatedThe 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. · F-0690
Oct 19, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · F-0692
Oct 19, 2023D · Potential for more than minimal harm, isolatedThe 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. · F-0756
Oct 19, 2023D · Potential for more than minimal harm, isolatedThe 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. · F-0759
Oct 19, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide timely, quality laboratory tests to meet residents' needs. · F-0770
Oct 19, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them. · F-0773
Oct 19, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. · F-0825
Oct 19, 2023D · Potential for more than minimal harm, isolatedThe facility did not have a proper governing body legally responsible for its policies and operations, or that body failed to appoint a properly licensed administrator to manage the facility. · F-0837
Oct 11, 2023E · Potential for more than minimal harm, patternThe 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 · F-0609

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (18 → 15).

Citations by recorded inspection yearPublished citation counts, not a quality score · Source: CMS, 2026-08-01
All citationsSerious citations (G–L)
2023
All citations: 18
Serious citations (G–L): 0
2024
All citations: 27
Serious citations (G–L): 0
2025
All citations: 49
Serious citations (G–L): 1
2026
All citations: 6
Serious citations (G–L): 0

All bars start at zero. Exact values and supporting details remain below.

YearCitationsSerious (G–L)Worst severity that year
2023180E
2024270E
2025491G ▲
202660E

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)

How to file a complaint about care →

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

What these staffing numbers mean →

Nurse time, in contextAdjusted hours per resident per day · Source: CMS, 2026-08-01
This facilityCalifornia averageU.S. average
Total nurse staffing (hours per resident per day)
This facility: 3.99
California average: 4.31
U.S. average: 3.95
Registered Nurse hours
This facility: 0.40
California average: 0.61
U.S. average: 0.69
Weekend total nurse staffing
This facility: 3.46
California average: 3.90
U.S. average: 3.50

All bars start at zero. Exact values and supporting details remain below.

MeasureThis facilityCalifornia avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.994.313.95bottom 40% in California; top 40% in the U.S.
Registered Nurse hours0.400.610.69bottom 34% in California; bottom 23% in the U.S.
Weekend total nurse staffing3.463.903.50bottom 27% in California; top 44% in the U.S.
Weekend RN hours (not acuity-adjusted)0.280.510.48bottom 28% in California; bottom 27% in the U.S.
Total nursing staff turnover (%)50.536.745.8bottom 13% in California; bottom 36% in the U.S.
RN turnover (%)50.038.142.9bottom 29% in California; bottom 39% in the U.S.

Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — 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 4.38, RN 0.44, weekend 3.80.Comparing with Medicare Care Compare? Care Compare shows the raw figure (4.38 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 3/5.

Quality measures: assessments & claims

Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.

Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 2/5

Costs & payment

Price evidence · separate from quality

No verified facility-specific private-pay price is available in our data for Monrovia Gardens Healthcare Center. CMS inspection and staffing records do not tell us what this home will charge you.

Calculate a stay from a quote you receive

Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.

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Understand who pays for care · How we handle price evidence · Report an incorrect price

Who owns this facility

How to read ownership records →

Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →

For profit - Limited Liability company

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
615 W. Duarte, LLCOrganizationADP of the SNFNOT APPLICABLE10/01/2003
Balacuit, DonaldIndividualOperational/Managerial ControlNOT APPLICABLE04/18/2024
Balacuit, DonaldIndividualADP of the SNFNOT APPLICABLE04/18/2024
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 APPLICABLE10/24/2025
Capela, HeidiIndividualOperational/Managerial ControlNOT APPLICABLE04/03/2023
Capela, HeidiIndividualADP of the SNFNOT APPLICABLE04/03/2023
Cruz, HayleyIndividualOperational/Managerial ControlNOT APPLICABLE04/01/2025
Hassell, LanceIndividualOperational/Managerial ControlNOT APPLICABLE04/25/2022
Hassell, LanceIndividualADP of the SNFNOT APPLICABLE04/25/2022
Lutz, LindaIndividualOperational/Managerial ControlNOT APPLICABLE02/01/2012
Lutz, LindaIndividualADP of the SNFNOT APPLICABLE02/01/2012
Salazar, PaulinaIndividualOperational/Managerial ControlNOT APPLICABLE12/14/2020
Salazar, PaulinaIndividualADP of the SNFNOT APPLICABLE12/14/2020
Smedra, IraIndividualOperational/Managerial ControlNOT APPLICABLE08/11/2003

Showing 20 of 31 parties CMS has on file for this facility; 11 are not displayed. The full list is in the CMS Ownership dataset.

Other facilities in the same chain

CMS lists this facility under the chain Cambridge Healthcare Services — 32 facilities in the current records. Chain membership says who operates these homes. It says nothing about how any individual one of them was inspected; each has its own record.

Listed by state, then facility name — not a ranking. Showing 8 of the 31 others, continuing from this facility's own place in that list.

Questions to ask on your visit

Full visit checklist →

Print visit checklist

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?"
  • "How often is each resident's medication list reviewed, and who decides when a drug can be reduced or stopped?"
  • "How do you explain health changes and treatment options to residents and their families?"
  • "How do you help residents maintain their daily living skills, and how do you measure whether it's working?"
  • "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
  • "How is routine foot care handled here, and does a podiatrist visit regularly?"
  • "How do you coordinate and monitor care for residents who receive dialysis?"
  • "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"

Also worth asking anywhere

  • "Your weekend nurse staffing is reported below the California midpoint — how does the weekend schedule differ from a weekday?"
  • "Can I see the plan of correction for the findings in your most recent state inspection?"
  • "CMS reports 51% total nursing staff turnover here — who on the care team has been with you longest?"
  • "The ownership record on file lists 31 owning or managing parties — who makes the decisions about staffing levels?"
  • "Can I visit again unannounced, at a mealtime or on a weekend?"

Nearby facilities (12 closest of 224 within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Monrovia Post Acute1.8 miDuarte, CA★★★☆☆2/5
Santa Fe Lodge1.8 miEl Monte, CA★★☆☆☆2/5
Mayflower Care Center1.8 miEl Monte, CA★★★☆☆3/5
Monte Vista Healthcare Center1.9 miDuarte, CA★★☆☆☆2/5
Huntington Drive Health and Rehabilitation Center2.3 miArcadia, CA★☆☆☆☆1/5
Royal Terrace Healthcare2.3 miDuarte, CA★★★☆☆2/5
Royal Oaks Manor-Bradbury Oaks2.4 miDuarte, CA★★★★☆3/5
Temple City Healthcare2.6 miTemple City, CA★★☆☆☆2/5
The Gardens of el Monte2.7 miEl Monte, CA★★☆☆☆2/5
Fidelity Health Care2.9 miEl Monte, CA★★★☆☆2/5abuse
Arcadia Care Center3.0 miArcadia, CA★★☆☆☆2/5
Baldwin Gardens Nursing Center3.0 miTemple City, CA★★★★☆4/5

Compare this facility with the 3 closest →

Other facilities in the same county

CMS records place this facility in Los Angeles, CA — 369 certified facilities there. These are outside the 20-mile list above, or far enough down it not to appear.

Listed by facility name — not a ranking. Homes already in the table above are not repeated here.

All facilities in Monrovia →

Facility data as of CMS processing date 2026-08-01. CCN 055367.

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