The Gardens of el Monte
5044 Buffington Rd, El Monte, CA 91732 · Los Angeles County · 53 certified beds · avg 51 residents/day · certified since Apr 18, 2017
Part of chain: THE MANDELBAUM FAMILY (18 facilities, chain avg rating 3.2★)
2/5
Health inspection rating (on-site)
1
Serious findings on record
$0
Fines, last 3 years
4.99
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 · Jun 17, 2024 · F-0692 · triggered by a complaint
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
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: Jul 18, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (60)
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 provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jun 24, 2026 | 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. · from a complaint |
| Jun 4, 2026 | E · Potential for harm, repeated | 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 10, 2026 | 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. |
| Apr 10, 2026 | E · Potential for harm, repeated | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Apr 10, 2026 | 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. |
| Apr 10, 2026 | 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. |
| Apr 10, 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. |
| Apr 10, 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 |
| Apr 10, 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 10, 2026 | 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. |
| Apr 10, 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. |
| Apr 10, 2026 | 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. |
| Apr 2, 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. · from a complaint |
| Dec 12, 2025 | E · Potential for harm, repeated | The facility did not honor residents' right to share a room with their spouse or a roommate of their choosing, or moved residents to a different room without written notice beforehand. · from a complaint |
| Dec 12, 2025 | E · Potential for harm, repeated | The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint |
| Dec 12, 2025 | E · Potential for harm, repeated | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint |
| Dec 12, 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 |
| Dec 12, 2025 | D · Potential for harm, one-off | The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. · from a complaint |
| Dec 1, 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. · from a complaint |
| Nov 14, 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. · from a complaint |
| Nov 14, 2025 | D · Potential for harm, one-off | The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). · from a complaint |
| Nov 6, 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 |
| Mar 16, 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 16, 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. |
| Mar 16, 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. |
| Mar 16, 2025 | E · Potential for harm, repeated | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Mar 16, 2025 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Mar 16, 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 16, 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 16, 2025 | 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 16, 2025 | 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. |
| Mar 16, 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. |
| Mar 16, 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. |
| Mar 16, 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. |
| Dec 23, 2024 | 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 |
| Dec 23, 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. · from a complaint |
| Dec 23, 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 |
| Aug 5, 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 |
| Jun 17, 2024 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Jun 17, 2024 | 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 16, 2024 | D · Potential for harm, one-off | The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly. · from a complaint |
| Apr 8, 2024 | 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. · from a complaint |
| Mar 15, 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. |
| Mar 15, 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. |
| Mar 15, 2024 | E · Potential for harm, repeated | 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. |
| Mar 15, 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. |
| Mar 15, 2024 | 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. |
| Mar 15, 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. |
| Mar 15, 2024 | E · Potential for harm, repeated | 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. |
| Mar 15, 2024 | D · Potential for harm, one-off | 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 15, 2024 | 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. |
| Mar 15, 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. |
| Mar 15, 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. |
| Mar 15, 2024 | D · Potential for harm, one-off | 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 15, 2024 | 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. |
| Mar 15, 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. |
| Mar 15, 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. |
| Aug 15, 2023 | D · Potential for harm, one-off | The facility did not let a resident or their legal representative see or buy copies of the resident's own records. · from a complaint |
| Aug 1, 2023 | 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 |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (12 → 10).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 2 | 0 | D |
| 2024 | 23 | 1 | G ▲ |
| 2025 | 21 | 0 | E |
| 2026 | 14 | 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)
0 fines totaling $0, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Jun 17, 2024 | Payment Denial | 1 days from Jul 17, 2024 |
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 | 0.32 | 0.61 | 0.69 | bottom 15% in California; bottom 11% in the U.S. |
| Weekend total nurse staffing | 4.47 | 3.90 | 3.50 | top 15% in California; top 12% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.19 | 0.51 | 0.48 | bottom 9% in California; bottom 11% in the U.S. |
| Total nursing staff turnover (%) | 57.4 | 36.7 | 45.8 | bottom 4% in California; bottom 20% in the U.S. |
| RN turnover (%) | 87.5 | 38.1 | 42.9 | bottom 1% in California; bottom 3% 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 4.78, RN 0.30, weekend 4.29. 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: 3/5 · short-stay residents: 5/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Simcha and Janet Mandelbaum Family Trust | Organization | 5% or Greater Indirect Ownership Interest | 20% | 01/01/2022 |
| The Bentzion Mandelbaum 2021 Irrevocable Gift Trust No. 2 | Organization | 5% or Greater Indirect Ownership Interest | 50% | 01/01/2023 |
| The Janet Mandelbaum 2021 Irrevocable Gift Trust No 2 | Organization | 5% or Greater Indirect Ownership Interest | 16% | 12/01/2021 |
| The Simcha Mandelbaum 2021 Irrevocable Gift Trust No. 2 | Organization | 5% or Greater Indirect Ownership Interest | 14% | 01/01/2023 |
| 5044 Buffington Road LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2023 |
| Castro-Garcia, Maria | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/06/2019 |
| Castro-Garcia, Maria | Individual | ADP of the SNF | NOT APPLICABLE | 11/06/2019 |
| Chiong, Mark | Individual | ADP of the SNF | NOT APPLICABLE | 04/07/2022 |
| Katiraie, Michael | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2023 |
| Katiraie, Michael | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/2023 |
| Mandelbaum, Brenda | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 05/29/2025 |
| Mandelbaum, Janet | Individual | Corporate Officer | NOT APPLICABLE | 01/02/2019 |
| Mandelbaum, Simcha | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2026 |
| Mandelbaum, Simcha | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2026 |
| Nlemchy-Okolo, Callista | Individual | ADP of the SNF | NOT APPLICABLE | 10/09/2023 |
| Olmos, Sergio | Individual | ADP of the SNF | NOT APPLICABLE | 12/16/2020 |
| Pham, Julie | Individual | ADP of the SNF | NOT APPLICABLE | 03/16/2000 |
| Randhawa, Harinder | Individual | ADP of the SNF | NOT APPLICABLE | 10/23/2023 |
| Schachten, Jeff | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/03/2025 |
| Schachten, Jeff | Individual | ADP of the SNF | NOT APPLICABLE | 02/03/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "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 |
|---|---|---|---|---|---|
| Fidelity Health Care | 0.6 mi | El Monte, CA | ★★★☆☆ | 2/5 | abuse |
| Santa Fe Lodge | 0.9 mi | El Monte, CA | ★★☆☆☆ | 2/5 | |
| Mayflower Care Center | 0.9 mi | El Monte, CA | ★★★☆☆ | 3/5 | |
| Temple City Healthcare | 1.2 mi | Temple City, CA | ★★☆☆☆ | 2/5 | |
| Penn Mar Healthcare Center | 1.3 mi | El Monte, CA | ★★☆☆☆ | 2/5 | |
| Madera Post Acute Center | 1.4 mi | El Monte, CA | ★☆☆☆☆ | 1/5 | |
| Eastland Subacute and Rehabilitation Center | 1.6 mi | El Monte, CA | ★★☆☆☆ | 2/5 | |
| Santa Anita Convalescent Hospital | 2.4 mi | Temple City, CA | ★☆☆☆☆ | 1/5 | SFF |
| Baldwin Gardens Nursing Center | 2.4 mi | Temple City, CA | ★★★★☆ | 4/5 | |
| Valley View Post Acute | 2.6 mi | El Monte, CA | ★★★☆☆ | 2/5 | |
| Monrovia Gardens Healthcare Center | 2.7 mi | Monrovia, CA | ★☆☆☆☆ | 1/5 | |
| Sunset Manor Conv Hosp | 2.8 mi | El Monte, CA | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 555903.