Rowntree Gardens
12151 Dale Avenue, Stanton, CA 90680 · Orange County · 58 certified beds · avg 43 residents/day · certified since Feb 19, 1998
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
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 (55)
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 | E · Potential for harm, repeated | 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. |
| Dec 11, 2025 | E · Potential for harm, repeated | The 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. |
| Dec 11, 2025 | E · Potential for harm, repeated | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Dec 11, 2025 | E · Potential for harm, repeated | The facility did not have enough staff with the right skills to meet the mental and behavioral health needs of its residents, such as those living with dementia or depression. |
| Dec 11, 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. |
| Dec 11, 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. |
| Dec 11, 2025 | E · Potential for harm, repeated | The 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. |
| Dec 11, 2025 | D · Potential for harm, one-off | The 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. |
| 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. |
| Dec 11, 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. |
| Dec 11, 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. |
| Dec 11, 2025 | 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. |
| Dec 11, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Dec 11, 2025 | 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. |
| Dec 11, 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. |
| Dec 11, 2025 | B · Minimal risk, repeated | 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. |
| Feb 10, 2025 | D · Potential for harm, one-off | The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. · from a complaint |
| Oct 29, 2024 | E · Potential for harm, repeated | 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. |
| Oct 29, 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. |
| Oct 29, 2024 | E · Potential for harm, repeated | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. |
| Oct 29, 2024 | D · Potential for harm, one-off | The 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. |
| Oct 29, 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. |
| Oct 29, 2024 | 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. |
| Oct 29, 2024 | 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. |
| Oct 29, 2024 | 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. |
| Oct 29, 2024 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Oct 29, 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. |
| Oct 29, 2024 | D · Potential for harm, one-off | 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. |
| Oct 29, 2024 | 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. |
| Oct 29, 2024 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Oct 29, 2024 | D · Potential for harm, one-off | The facility did not have a policy covering how food brought in by family and visitors is used and stored safely. |
| Oct 29, 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. |
| Oct 29, 2024 | D · Potential for harm, one-off | The 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. |
| Oct 29, 2024 | B · Minimal risk, repeated | 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. |
| Oct 29, 2024 | B · Minimal risk, repeated | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Mar 3, 2023 | 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. |
| Mar 3, 2023 | 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. |
| Mar 3, 2023 | 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. |
| Mar 3, 2023 | D · Potential for harm, one-off | 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. |
| Mar 3, 2023 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Mar 3, 2023 | 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. |
| Mar 3, 2023 | 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. |
| Mar 3, 2023 | 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. |
| Mar 3, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Mar 3, 2023 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Mar 3, 2023 | 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. |
| Mar 3, 2023 | 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. |
| Mar 3, 2023 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Mar 3, 2023 | 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. |
| Mar 3, 2023 | D · Potential for harm, one-off | 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. |
| Mar 3, 2023 | 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. |
| Mar 3, 2023 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Mar 3, 2023 | D · Potential for harm, one-off | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Mar 3, 2023 | 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. |
| Mar 3, 2023 | D · Potential for harm, one-off | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (18 → 16).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 20 | 0 | E |
| 2024 | 18 | 0 | E |
| 2025 | 17 | 0 | 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) | 4.99 | 4.31 | 3.95 | top 15% in California; top 13% in the U.S. |
| Registered Nurse hours | 0.48 | 0.61 | 0.69 | bottom 50% in California; bottom 35% in the U.S. |
| Weekend total nurse staffing | 4.41 | 3.90 | 3.50 | top 17% in California; top 14% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.45 | 0.51 | 0.48 | top 38% in California; top 40% in the U.S. |
| Total nursing staff turnover (%) | 35.0 | 36.7 | 45.8 | top 46% in California; top 24% in the U.S. |
| RN turnover (%) | 0.0 | 38.1 | 42.9 | top 1% in California; top 1% 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 5.60, RN 0.54, weekend 4.95. 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: 5/5
Who owns this facility
Non profit - Church related
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| California Friends Homes | Organization | 5% or Greater Direct Ownership Interest | 100% | 04/01/1999 |
| Amali, Babak | Individual | Corporate Director | NOT APPLICABLE | 02/17/2026 |
| Brown, Randal | Individual | Corporate Director | NOT APPLICABLE | 01/01/2025 |
| Butler, Bruce | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Clark, Kerri | Individual | Corporate Director | NOT APPLICABLE | 01/01/2019 |
| Clark, Kerri | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2019 |
| Clark, Kerri | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2019 |
| Dollarhide, Carol | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/19/2026 |
| Dollarhide, Carol | Individual | ADP of the SNF | NOT APPLICABLE | 01/19/2026 |
| Drake, William | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Ellis, Richard | Individual | Corporate Director | NOT APPLICABLE | 02/17/2026 |
| Fujikawa, Iris | Individual | Corporate Director | NOT APPLICABLE | 02/17/2026 |
| Glasgow, Gordon | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2005 |
| Glasgow, Gordon | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2005 |
| Johnson, Gary | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Laney, Penny | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/05/2015 |
| Laney, Penny | Individual | ADP of the SNF | NOT APPLICABLE | 01/05/2015 |
| Marqueses, Mary Grace | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/11/2019 |
| Marqueses, Mary Grace | Individual | ADP of the SNF | NOT APPLICABLE | 11/11/2019 |
| Marston, Melinda | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/04/2016 |
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 percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
- "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
- "What training does your staff have in dementia and behavioral health, and how many residents with these needs do you serve?"
- "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?"
- "Who oversees antibiotic use here, and how do you decide when an antibiotic is really needed?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "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 |
|---|---|---|---|---|---|
| Garden Grove Post Acute | 1.0 mi | Garden Grove, CA | ★★★★☆ | 3/5 | |
| Extended Care Hospital of Westminster | 1.7 mi | Westminster, CA | ★★★★☆ | 3/5 | |
| Mission Palms Healthcare Center | 1.9 mi | Westminster, CA | ★★★☆☆ | 2/5 | |
| Coventry Court Health Center | 2.7 mi | Anaheim, CA | ★★★★☆ | 3/5 | |
| Beach Creek Post-Acute | 2.7 mi | Anaheim, CA | ★★★☆☆ | 3/5 | |
| Park Anaheim Healthcare Center | 2.8 mi | Anaheim, CA | ★★☆☆☆ | 2/5 | |
| Anaheim Point | 2.8 mi | Anaheim, CA | ★★☆☆☆ | 1/5 | |
| Anaheim Healthcare Center, LLC | 2.8 mi | Anaheim, CA | ★★★☆☆ | 2/5 | |
| Buena Vista Care Center | 2.9 mi | Anaheim, CA | ★★★☆☆ | 3/5 | |
| Anaheim Crest Nursing Center | 2.9 mi | Anaheim, CA | ★★★☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 555718.