Sunset Manor Conv Hosp
2720 Nevada Avenue, El Monte, CA 91733 · Los Angeles County · 81 certified beds · avg 73 residents/day · certified since Jun 18, 1969
Part of chain: DAVID JOHNSON (48 facilities, chain avg rating 3.2★)
3/5
Health inspection rating (on-site)
1
Serious findings on record
$0
Fines, last 3 years
3.86
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · 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, one-off · Jan 3, 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): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 20, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (52)
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 |
|---|---|---|
| May 22, 2026 | E · Potential for harm, repeated | 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. |
| May 22, 2026 | 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. |
| May 22, 2026 | 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. |
| May 22, 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. |
| May 22, 2026 | 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. |
| May 22, 2026 | D · Potential for harm, one-off | 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. |
| May 22, 2026 | 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 22, 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. |
| May 22, 2026 | 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 22, 2026 | D · Potential for harm, one-off | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Jan 12, 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 |
| Nov 26, 2025 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Nov 20, 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 |
| Nov 20, 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. · from a complaint |
| Mar 21, 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. |
| Mar 21, 2025 | E · Potential for harm, repeated | The 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. |
| Mar 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. |
| Mar 21, 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. |
| Mar 21, 2025 | D · Potential for harm, one-off | 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. |
| Mar 21, 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. |
| Mar 21, 2025 | 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 21, 2025 | D · Potential for harm, one-off | The facility did not properly inform residents or their representatives about arbitration agreements — contracts that give up the right to sue in court — including their right to refuse to sign. |
| Mar 21, 2025 | B · Minimal risk, repeated | The facility had resident rooms holding more people than allowed — no more than 4 residents per room, and no more than 2 per room in buildings constructed after November 28, 2016. |
| Mar 21, 2025 | B · Minimal risk, repeated | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. |
| Jan 21, 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. · from a complaint |
| Jan 3, 2025 | ▲ G · Actual 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 |
| Jan 3, 2025 | D · Potential for harm, one-off | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. · from a complaint |
| Aug 20, 2024 | 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. · from a complaint |
| Aug 13, 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. · from a complaint |
| Aug 13, 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. · from a complaint |
| Jul 24, 2024 | D · Potential for harm, one-off | 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. · from a complaint |
| Apr 12, 2024 | E · Potential for harm, repeated | 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. |
| Apr 12, 2024 | 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. |
| Apr 12, 2024 | E · Potential for harm, repeated | 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. |
| Apr 12, 2024 | E · Potential for harm, repeated | 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 12, 2024 | 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. |
| Apr 12, 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. |
| Apr 12, 2024 | 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 12, 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. |
| Apr 12, 2024 | D · Potential for harm, one-off | 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. |
| Apr 12, 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. |
| Apr 12, 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. |
| Apr 12, 2024 | D · Potential for harm, one-off | 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. |
| Apr 12, 2024 | 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 12, 2024 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Apr 12, 2024 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. |
| Apr 12, 2024 | B · Minimal risk, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Apr 12, 2024 | B · Minimal risk, repeated | The facility had resident rooms holding more people than allowed — no more than 4 residents per room, and no more than 2 per room in buildings constructed after November 28, 2016. |
| Apr 12, 2024 | B · Minimal risk, repeated | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. |
| Mar 4, 2024 | 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 |
| Feb 6, 2024 | 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 |
| Oct 27, 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. · from a complaint |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (10 → 10).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 1 | 0 | D |
| 2024 | 24 | 0 | E |
| 2025 | 16 | 1 | G ▲ |
| 2026 | 11 | 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) | 3.86 | 4.31 | 3.95 | bottom 31% in California; top 46% in the U.S. |
| Registered Nurse hours | 0.40 | 0.61 | 0.69 | bottom 32% in California; bottom 22% in the U.S. |
| Weekend total nurse staffing | 3.47 | 3.90 | 3.50 | bottom 27% in California; top 43% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.23 | 0.51 | 0.48 | bottom 17% in California; bottom 17% in the U.S. |
| Total nursing staff turnover (%) | 45.2 | 36.7 | 45.8 | bottom 25% in California; bottom 49% in the U.S. |
| RN turnover (%) | 57.1 | 38.1 | 42.9 | bottom 18% in California; bottom 26% 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 4.48, RN 0.46, weekend 4.03. 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: 4/5 · long-stay residents: 5/5 · short-stay residents: 2/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Gibraltar Convalescent Hospital INC | Organization | 5% or Greater Direct Ownership Interest | 100% | 04/01/1977 |
| Dehghanmanesh, Adrian | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2021 |
| Johnson, Frank | Individual | Corporate Director | NOT APPLICABLE | 04/01/1977 |
| Presnell, William | Individual | Corporate Director | NOT APPLICABLE | 04/01/1977 |
| Presnell, William | Individual | Corporate Officer | NOT APPLICABLE | 10/10/1986 |
| Stewart, Selina | Individual | W-2 Managing Employee | NOT APPLICABLE | 01/23/2020 |
| Sun Mar Management Services | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/1977 |
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?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "How do you help residents maintain their daily living skills, and how do you measure whether it's working?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "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 |
|---|---|---|---|---|---|
| Valley View Post Acute | 0.3 mi | El Monte, CA | ★★★☆☆ | 2/5 | |
| Greater el Monte Community Hos | 0.9 mi | El Monte, CA | ★★★★☆ | 4/5 | |
| Madera Post Acute Center | 1.5 mi | El Monte, CA | ★☆☆☆☆ | 1/5 | |
| Eastland Subacute and Rehabilitation Center | 1.9 mi | El Monte, CA | ★★☆☆☆ | 2/5 | |
| Rosemead Healthcare Center | 1.9 mi | El Monte, CA | ★★☆☆☆ | 2/5 | |
| Penn Mar Healthcare Center | 2.0 mi | El Monte, CA | ★★☆☆☆ | 2/5 | |
| Fidelity Health Care | 2.4 mi | El Monte, CA | ★★★☆☆ | 2/5 | abuse |
| Temple City Healthcare | 2.7 mi | Temple City, CA | ★★☆☆☆ | 2/5 | |
| The Gardens of el Monte | 2.8 mi | El Monte, CA | ★★☆☆☆ | 2/5 | |
| Santa Anita Convalescent Hospital | 2.9 mi | Temple City, CA | ★☆☆☆☆ | 1/5 | SFF |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 055104.