Monte Vista Healthcare Center

Name: Monte Vista Healthcare Center
Address: 802 BUENA VISTA STREET, Duarte, CA, 91010, US
Telephone: 6263598141

802 Buena Vista Street, Duarte, CA 91010 · Los Angeles County · 69 certified beds · avg 62 residents/day · certified since Sep 5, 1967

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

2/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

4.10

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 (47)

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 3, 2026	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. · from a complaint
Apr 24, 2026	E · Potential for harm, repeated	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.
Apr 24, 2026	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Apr 24, 2026	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 24, 2026	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.
Apr 24, 2026	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 24, 2026	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.
Apr 24, 2026	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 24, 2026	D · Potential for harm, one-off	The 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.
Apr 24, 2026	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.
Apr 24, 2026	D · Potential for harm, one-off	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.
Apr 24, 2026	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.
Apr 24, 2026	D · Potential for harm, one-off	The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.
Mar 4, 2026	E · Potential for harm, repeated	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
Mar 4, 2026	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. · from a complaint
Feb 17, 2026	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
Jan 9, 2026	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. · from a complaint
Jan 9, 2026	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
Jan 9, 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
Jul 23, 2025	D · Potential for harm, one-off	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. · from a complaint
Jul 23, 2025	D · Potential for harm, one-off	The facility did not dispose of garbage and refuse properly. · from a complaint
Feb 21, 2025	E · Potential for harm, repeated	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Feb 21, 2025	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Feb 21, 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.
Feb 21, 2025	E · Potential for harm, repeated	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.
Feb 21, 2025	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.
Feb 21, 2025	E · Potential for harm, repeated	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.
Feb 21, 2025	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.
Feb 21, 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.
Feb 21, 2025	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.
Feb 21, 2025	E · Potential for harm, repeated	The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Feb 21, 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.
Feb 21, 2025	D · Potential for harm, one-off	The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Feb 21, 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.
Feb 21, 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.
Feb 21, 2025	D · Potential for harm, one-off	The 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.
Feb 21, 2025	D · Potential for harm, one-off	The 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.
Feb 21, 2025	D · Potential for harm, one-off	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Feb 21, 2025	D · Potential for harm, one-off	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.
Feb 21, 2025	D · Potential for harm, one-off	The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests.
Feb 11, 2024	E · Potential for harm, repeated	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.
Feb 11, 2024	E · Potential for harm, repeated	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.
Feb 11, 2024	E · Potential for harm, repeated	The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids.
Feb 11, 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.
Feb 11, 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.
Feb 11, 2024	D · Potential for harm, one-off	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.
Feb 11, 2024	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 decreased between the last two inspection cycles (19 → 12).

Year	Citations	Worst severity that year
2024	7	E
2025	21	E
2026	19	E

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)	4.10	4.31	3.95	bottom 48% in California; top 36% in the U.S.
Registered Nurse hours	0.36	0.61	0.69	bottom 23% in California; bottom 16% in the U.S.
Weekend total nurse staffing	3.62	3.90	3.50	bottom 41% in California; top 37% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.20	0.51	0.48	bottom 11% in California; bottom 13% in the U.S.
Total nursing staff turnover (%)	47.6	36.7	45.8	bottom 19% in California; bottom 43% in the U.S.
RN turnover (%)	33.3	38.1	42.9	top 40% in California; top 33% 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 4.20, RN 0.37, 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: 3/5 · long-stay residents: 4/5 · short-stay residents: 2/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Win Win Enterprises, LLC	Organization	5% or Greater Direct Ownership Interest	45%	02/19/2003
802 Buena Vista Street, LLC	Organization	ADP of the SNF	NOT APPLICABLE	04/01/2003
BH Alliance	Organization	ADP of the SNF	NOT APPLICABLE	04/01/2003
Butenko, Julie	Individual	Operational/Managerial Control	NOT APPLICABLE	07/24/2023
Butenko, Julie	Individual	ADP of the SNF	NOT APPLICABLE	07/24/2023
Cambridge Healthcare Services LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	04/01/2014
Cambridge Healthcare Services LLC	Organization	ADP of the SNF	NOT APPLICABLE	10/24/2025
Capela, Heidi	Individual	Operational/Managerial Control	NOT APPLICABLE	04/03/2023
Capela, Heidi	Individual	ADP of the SNF	NOT APPLICABLE	04/03/2023
Gazarian, Levon	Individual	Operational/Managerial Control	NOT APPLICABLE	09/09/2013
Gazarian, Levon	Individual	ADP of the SNF	NOT APPLICABLE	09/09/2013
Hassell, Lance	Individual	Operational/Managerial Control	NOT APPLICABLE	04/25/2022
Hassell, Lance	Individual	ADP of the SNF	NOT APPLICABLE	04/25/2022
Lawler, Emelyn	Individual	Managing Control - Governing Body	NOT APPLICABLE	04/10/2024
Lawler, Emelyn	Individual	Operational/Managerial Control	NOT APPLICABLE	04/10/2024
Lawler, Emelyn	Individual	ADP of the SNF	NOT APPLICABLE	10/24/2025
Lutz, Linda	Individual	Operational/Managerial Control	NOT APPLICABLE	02/01/2012
Lutz, Linda	Individual	ADP of the SNF	NOT APPLICABLE	02/01/2012
Salazar, Paulina	Individual	Operational/Managerial Control	NOT APPLICABLE	12/14/2020
Salazar, Paulina	Individual	ADP of the SNF	NOT APPLICABLE	12/14/2020

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How do you keep residents' medical records accurate, complete, and secure?"
"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?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
"What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"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
Monrovia Post Acute	0.3 mi	Duarte, CA	★★★☆☆	2/5
Royal Oaks Manor-Bradbury Oaks	0.6 mi	Duarte, CA	★★★★☆	3/5
Royal Terrace Healthcare	0.7 mi	Duarte, CA	★★★☆☆	2/5
Monrovia Gardens Healthcare Center	1.9 mi	Monrovia, CA	★☆☆☆☆	1/5
Santa Fe Lodge	3.1 mi	El Monte, CA	★★☆☆☆	2/5
Mayflower Care Center	3.1 mi	El Monte, CA	★★★☆☆	3/5
Sierra View Care Center	3.5 mi	Baldwin Park, CA	★★★★☆	3/5
Coast Care Convalescent Center	3.7 mi	Baldwin Park, CA	★★★★☆	4/5
The Gardens of el Monte	3.9 mi	El Monte, CA	★★☆☆☆	2/5
Huntington Drive Health and Rehabilitation Center	4.1 mi	Arcadia, CA	★☆☆☆☆	1/5
Temple City Healthcare	4.2 mi	Temple City, CA	★★☆☆☆	2/5
Fidelity Health Care	4.2 mi	El Monte, CA	★★★☆☆	2/5	abuse

Compare this facility with the 3 closest →

All facilities in Duarte →

Facility data as of CMS processing date 2026-08-01. CCN 055817.

The Care File

Visit checklist — Monte Vista Healthcare Center

802 Buena Vista Street, Duarte, CA 91010 · 6263598141

Health inspection rating 2/5 · CMS overall 2/5· Fines (3y): $0

Questions for the administrator:

☐ "How do you keep residents' medical records accurate, complete, and secure?"
☐ "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?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
☐ "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "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?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 055817 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)