Sunset Park Healthcare
2250 29th Street, Santa Monica, CA 90405 · Los Angeles County · 44 certified beds · avg 42 residents/day · certified since May 25, 1967
Part of chain: ABRAHAM BAK & MENACHEM GASTWIRTH (18 facilities, chain avg rating 2.5★)
2/5
Health inspection rating (on-site)
1
Serious findings on record
$0
Fines, last 3 years
4.03
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.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Oct 5, 2023 · 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: Oct 27, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (58)
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 |
|---|---|---|
| Mar 24, 2026 | D · Potential for harm, one-off | The 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 |
| Feb 27, 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 |
| Oct 3, 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. · from a complaint |
| Jun 17, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to receive the visitors they choose, at the times they choose. · from a complaint |
| Jun 17, 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 |
| May 25, 2025 | 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 25, 2025 | 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. |
| May 25, 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. |
| May 25, 2025 | E · Potential for harm, repeated | The facility did not provide routine dental care and 24-hour emergency dental care for residents. |
| May 25, 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. |
| May 25, 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. |
| May 25, 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. |
| May 25, 2025 | E · Potential for harm, repeated | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| May 25, 2025 | E · Potential for harm, 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. |
| May 25, 2025 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| May 25, 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. |
| May 25, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| May 25, 2025 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| May 25, 2025 | 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. |
| May 25, 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. |
| May 25, 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. |
| May 25, 2025 | 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. |
| May 25, 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. |
| May 25, 2025 | 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. |
| May 25, 2025 | D · Potential for harm, one-off | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. |
| May 25, 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. |
| May 25, 2025 | 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. |
| May 25, 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. |
| May 7, 2025 | D · Potential for harm, one-off | The 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 |
| Apr 15, 2025 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · from a complaint |
| Apr 4, 2025 | 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 |
| Apr 4, 2025 | 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 |
| Nov 22, 2024 | 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. · from a complaint |
| Nov 22, 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. · from a complaint |
| Aug 19, 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 |
| Jun 18, 2024 | D · Potential for harm, one-off | The 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 |
| Jun 18, 2024 | 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 |
| May 27, 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 27, 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. |
| May 27, 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. |
| Oct 18, 2023 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Oct 5, 2023 | ▲ 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 |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · from a complaint |
| Sep 12, 2023 | 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. · from a complaint |
| Jan 27, 2022 | E · Potential for harm, 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. |
| Jan 27, 2022 | 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. |
| Jan 27, 2022 | E · Potential for harm, repeated | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Jan 27, 2022 | E · Potential for harm, repeated | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| Jan 27, 2022 | 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. |
| Jan 27, 2022 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jan 27, 2022 | 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. |
| Jan 27, 2022 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jan 27, 2022 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| Jan 27, 2022 | 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. |
| Jan 27, 2022 | 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. |
| Jan 27, 2022 | 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. |
| Jan 27, 2022 | 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. |
| Jan 27, 2022 | 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. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 23).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 14 | 0 | E |
| 2023 | 4 | 1 | G ▲ |
| 2024 | 8 | 0 | E |
| 2025 | 30 | 0 | E |
| 2026 | 2 | 0 | D |
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) | 4.03 | 4.31 | 3.95 | bottom 43% in California; top 38% in the U.S. |
| Registered Nurse hours | 0.28 | 0.61 | 0.69 | bottom 9% in California; bottom 8% in the U.S. |
| Weekend total nurse staffing | 3.52 | 3.90 | 3.50 | bottom 32% in California; top 41% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.25 | 0.51 | 0.48 | bottom 21% in California; bottom 21% in the U.S. |
| Total nursing staff turnover (%) | 30.2 | 36.7 | 45.8 | top 30% in California; top 14% in the U.S. |
| 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 4.63, RN 0.32, weekend 4.04. 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: 4/5 · short-stay residents: 4/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Abe and Rachel Bak Family Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2021 |
| Am Holdco, LLC | Organization | 5% or Greater Direct Ownership Interest | 10% | 05/01/2023 |
| Bak, Rachel | Individual | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2021 |
| Lehmann, Kenneth | Individual | 5% or Greater Direct Ownership Interest | 25% | 05/01/2021 |
| Moas, Aaron | Individual | 5% or Greater Direct Ownership Interest | 14% | 05/01/2021 |
| Oscherowitz, Avishai | Individual | 5% or Greater Direct Ownership Interest | 5% | 05/01/2023 |
| Abak Consulting LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/27/2021 |
| Bak, Abraham | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2021 |
| Bak, Abraham | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2021 |
| Bak, Abraham | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2021 |
| Gastwirth, Menachem | Individual | Managing Control - Governing Body | NOT APPLICABLE | 03/06/2020 |
| Gastwirth, Menachem | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2021 |
| Gastwirth, Menachem | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2021 |
| Gewirtz, Chonoch | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2021 |
| Lehmann, Kenneth | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2021 |
| Lehmann, Kenneth | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2021 |
| Mgaz Consulting LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/27/2021 |
| Montag, Memphis | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2023 |
| Montag, Memphis | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2023 |
| Rutherford, Keino | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2025 |
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?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "What are your visiting policies — can family visit any time the resident wants?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How do you arrange eye and hearing care for residents, including appointments and equipment like glasses or hearing aids?"
- "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
- "How do residents get routine dental care, and what happens if someone has a dental emergency at night?"
- "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 |
|---|---|---|---|---|---|
| Ocean Park Healthcare | 0.0 mi | Santa Monica, CA | ★★☆☆☆ | 2/5 | |
| Westwood Post Acute Care | 1.1 mi | Los Angeles, CA | ★★☆☆☆ | 2/5 | abuse |
| Brentwood Health Care Center | 1.2 mi | Santa Monica, CA | ★★★☆☆ | 3/5 | |
| Ocean Pointe Healthcare Center | 1.2 mi | Santa Monica, CA | ★★☆☆☆ | 2/5 | |
| Berkley West Healthcare Center | 1.2 mi | Santa Monica, CA | ★★★☆☆ | 2/5 | |
| Pacific Post Acute | 1.2 mi | Santa Monica, CA | ★★★★★ | 4/5 | |
| Santa Monica Rehabilitation Center | 1.2 mi | Santa Monica, CA | ★☆☆☆☆ | 1/5 | abuseSFF |
| Santa Monica Health Care Center | 1.2 mi | Santa Monica, CA | ★★★☆☆ | 3/5 | |
| Berkley East Healthcare Center | 1.2 mi | Santa Monica, CA | ★★☆☆☆ | 1/5 | |
| Good Shepherd Health Care Center of Santa Monica | 1.7 mi | Santa Monica, CA | ★★☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 055748.