Mount San Antonio Gardens

Name: Mount San Antonio Gardens
Address: 900 E. HARRISON AVE, Pomona, CA, 91767, US
Telephone: 9096245061

900 E. Harrison Ave, Pomona, CA 91767 · Los Angeles County · 64 certified beds · avg 40 residents/day · certified since Jan 1, 1967

5/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

6.84

Nurse hours/resident/day (adjusted)

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

Health inspection rating: ★★★★★5/5 · CMS overall rating: 5/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (14)

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 24, 2026	E · Potential for harm, repeated	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jun 24, 2026	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.
Jun 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.
Jun 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.
Jun 24, 2026	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.
Jan 22, 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. · from a complaint
May 30, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
May 30, 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.
May 30, 2025	D · Potential for harm, one-off	The 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.
May 30, 2025	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.
May 16, 2024	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.
May 16, 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.
May 16, 2024	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.
May 16, 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 stayed about the same across the last two inspection cycles (4 → 5).

Year	Citations	Worst severity that year
2024	4	E
2025	4	D
2026	6	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)	6.84	4.31	3.95	top 3% in California; top 2% in the U.S.
Registered Nurse hours	0.84	0.61	0.69	top 16% in California; top 24% in the U.S.
Weekend total nurse staffing	5.50	3.90	3.50	top 4% in California; top 3% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.54	0.51	0.48	top 26% in California; top 28% in the U.S.
Total nursing staff turnover (%)	0.0	36.7	45.8	—
RN turnover (%)	0.0	38.1	42.9	—

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 5.95, RN 0.73, weekend 4.79. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

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

Who owns this facility

Non profit - Corporation

Owner / manager	Type	Role	Stake	Since
Congregational Homes	Organization	5% or Greater Direct Ownership Interest	100%	06/09/2007
Abrams, Lise	Individual	Corporate Director	NOT APPLICABLE	01/01/2023
Abrams, Lise	Individual	Operational/Managerial Control	NOT APPLICABLE	01/01/2023
Abrams, Lise	Individual	ADP of the SNF	NOT APPLICABLE	01/01/2023
Aspinall, Robin	Individual	Corporate Director	NOT APPLICABLE	01/01/2023
Aspinall, Robin	Individual	Operational/Managerial Control	NOT APPLICABLE	01/01/2023
Aspinall, Robin	Individual	ADP of the SNF	NOT APPLICABLE	01/01/2023
Atilano, Lisa	Individual	Corporate Officer	NOT APPLICABLE	07/25/2024
Atilano, Lisa	Individual	Operational/Managerial Control	NOT APPLICABLE	07/25/2024
Atilano, Lisa	Individual	ADP of the SNF	NOT APPLICABLE	07/25/2024
Brown, Eleanor	Individual	Corporate Director	NOT APPLICABLE	01/01/2021
Brown, Eleanor	Individual	Operational/Managerial Control	NOT APPLICABLE	01/01/2021
Brown, Eleanor	Individual	ADP of the SNF	NOT APPLICABLE	01/01/2021
Brown, Evelyn	Individual	Corporate Director	NOT APPLICABLE	01/06/2022
Brown, Evelyn	Individual	Operational/Managerial Control	NOT APPLICABLE	01/06/2022
Brown, Evelyn	Individual	ADP of the SNF	NOT APPLICABLE	01/01/2021
Bush, Jan	Individual	Corporate Director	NOT APPLICABLE	01/01/2023
Bush, Jan	Individual	Operational/Managerial Control	NOT APPLICABLE	01/01/2023
Bush, Jan	Individual	ADP of the SNF	NOT APPLICABLE	01/01/2023
Citrus Pharmacy	Organization	Operational/Managerial Control	NOT APPLICABLE	08/01/2025

Questions to ask on your visit

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

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
"How is pest control handled here, and when was the last treatment or inspection?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
"What alternatives do you try before using bed rails, and how do you involve families in that decision?"
"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
Pilgrim Place Health Services Center	0.6 mi	Claremont, CA	★★★☆☆	2/5
Claremont Manor Care Center	0.6 mi	Claremont, CA	★★★☆☆	3/5
Claremont Care Center	0.8 mi	Pomona, CA	★★★★☆	3/5
Landmark Medical Center	1.2 mi	Pomona, CA	★★☆☆☆	1/5	abuse
Claremont Heights Post Acute	1.5 mi	Claremont, CA	★★☆☆☆	2/5
Inland Valley Care and Rehabilitation Center	1.6 mi	Pomona, CA	★☆☆☆☆	1/5	abuseSFF
Park Avenue Healthcare & Wellness Center	1.8 mi	Pomona, CA	★☆☆☆☆	1/5
Woods Health Services	2.3 mi	La Verne, CA	★★★☆☆	2/5
Country Oaks Care Center	2.4 mi	Pomona, CA	★★★☆☆	2/5
Pomona Vista Care Center	2.5 mi	Pomona, CA	★★★★☆	3/5

Compare this facility with the 3 closest →

All facilities in Pomona →

Facility data as of CMS processing date 2026-08-01. CCN 055016.

The Care File

Visit checklist — Mount San Antonio Gardens

900 E. Harrison Ave, Pomona, CA 91767 · 9096245061

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

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
☐ "How is pest control handled here, and when was the last treatment or inspection?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
☐ "What alternatives do you try before using bed rails, and how do you involve families in that decision?"
☐ "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 055016 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)