Victoria Care Center

Name: Victoria Care Center
Address: 3541 PUENTE AVENUE, Baldwin Park, CA, 91706, US
Telephone: 6269621043

3541 Puente Avenue, Baldwin Park, CA 91706 · Los Angeles County · 49 certified beds · avg 42 residents/day · certified since Feb 5, 1979

Part of chain: DAVID JOHNSON (48 facilities, chain avg rating 3.2★)

4/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

4.24

Nurse hours/resident/day (adjusted)

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

Health inspection rating: ★★★★☆4/5 · 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 (36)

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
Apr 9, 2026	E · Potential for harm, 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 9, 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.
Apr 9, 2026	E · Potential for harm, 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.
Apr 9, 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.
Apr 9, 2026	E · Potential for harm, repeated	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 9, 2026	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.
Apr 9, 2026	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.
Apr 9, 2026	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.
Apr 9, 2026	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.
Apr 9, 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.
Jun 12, 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. · from a complaint
May 16, 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. · from a complaint
Feb 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.
Feb 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.
Feb 16, 2025	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.
Feb 16, 2025	E · Potential for harm, repeated	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.
Feb 16, 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.
Feb 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.
Feb 16, 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.
Feb 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.
Nov 5, 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
Jun 13, 2024	D · Potential for harm, one-off	The facility did not let a resident return after a hospital stay or approved leave that lasted longer than the facility's bed-hold policy allowed. Residents generally have the right to come back to the next available bed. · from a complaint
Feb 11, 2024	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.
Feb 11, 2024	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.
Feb 11, 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.
Feb 11, 2024	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.
Feb 11, 2024	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.
Feb 11, 2024	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.
Feb 11, 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.
Feb 11, 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.
Feb 11, 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.
Feb 11, 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.
Feb 11, 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.
Feb 11, 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.
Feb 11, 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.
Jan 9, 2024	D · Potential for harm, one-off	The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · from a complaint

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (8 → 10).

Year	Citations	Worst severity that year
2024	16	E
2025	10	E
2026	10	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)	4.24	4.31	3.95	top 42% in California; top 31% in the U.S.
Registered Nurse hours	0.38	0.61	0.69	bottom 29% in California; bottom 20% in the U.S.
Weekend total nurse staffing	3.80	3.90	3.50	top 46% in California; top 29% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.27	0.51	0.48	bottom 26% in California; bottom 25% in the U.S.
Total nursing staff turnover (%)	42.6	36.7	45.8	bottom 31% in California; top 43% in the U.S.
RN turnover (%)	33.3	38.1	42.9	top 40% in California; top 33% 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 4.55, RN 0.41, weekend 4.07. 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

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Puente Partners LLC	Organization	5% or Greater Direct Ownership Interest	100%	10/30/2008
Brice, Joshua	Individual	Operational/Managerial Control	NOT APPLICABLE	10/24/2024
Brice, Joshua	Individual	ADP of the SNF	NOT APPLICABLE	10/24/2024
Chimwaza, Pearson	Individual	Operational/Managerial Control	NOT APPLICABLE	09/16/2024
Chimwaza, Pearson	Individual	ADP of the SNF	NOT APPLICABLE	09/16/2024
Dehghanmanesh, Adrian	Individual	Operational/Managerial Control	NOT APPLICABLE	06/01/2021
Dehghanmanesh, Adrian	Individual	ADP of the SNF	NOT APPLICABLE	06/01/2021
Dhiman, Naveen	Individual	Operational/Managerial Control	NOT APPLICABLE	08/10/2024
Dhiman, Naveen	Individual	ADP of the SNF	NOT APPLICABLE	01/01/2023
Farrales, Mary	Individual	ADP of the SNF	NOT APPLICABLE	01/01/2023
Johnson, Frank	Individual	Managing Control - Governing Body	NOT APPLICABLE	06/10/2008
Johnson, Frank	Individual	Operational/Managerial Control	NOT APPLICABLE	06/10/2008
Kochek, Joshua	Individual	Operational/Managerial Control	NOT APPLICABLE	04/01/2022
Kochek, Joshua	Individual	ADP of the SNF	NOT APPLICABLE	04/01/2022
Oxford, Micheal	Individual	Operational/Managerial Control	NOT APPLICABLE	01/03/2022
Oxford, Micheal	Individual	ADP of the SNF	NOT APPLICABLE	01/03/2022
Puente Partners LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	10/30/2008
Puente Partners LLC	Organization	ADP of the SNF	NOT APPLICABLE	10/30/2008
Rose Baldwin Park Property LP	Organization	5% or Greater Security Interest	NOT APPLICABLE	02/11/2025
Rose Baldwin Park Property LP	Organization	ADP of the SNF	NOT APPLICABLE	02/11/2025

Questions to ask on your visit

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

"Who completes resident assessments here, and how do you check them for accuracy?"
"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 many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
"Where do you post your daily staffing numbers, and can I see today's?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
"How do you decide when a feeding tube is truly needed, and how do staff care for residents who have one?"
"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
West Covina Healthcare Center	0.5 mi	West Covina, CA	★★★☆☆	3/5
West Covina Medical Center D/P SNF	0.7 mi	West Covina, CA	★★★★☆	4/5
Garden View Post Acute Rehabilitation	0.8 mi	Baldwin Park, CA	★★★★☆	3/5
West Haven Healthcare	0.8 mi	West Covina, CA	★★★★☆	3/5
Coast Care Convalescent Center	1.2 mi	Baldwin Park, CA	★★★★☆	4/5
Sierra View Care Center	1.4 mi	Baldwin Park, CA	★★★★☆	3/5
Clara Baldwin Stocker Home for Women	1.4 mi	West Covina, CA	★★★☆☆	2/5
Beacon Healthcare Center	1.8 mi	West Covina, CA	★★★★★	4/5
The Rowland	2.9 mi	Covina, CA	★☆☆☆☆	1/5
Harvard Creek Post Acute	2.9 mi	Covina, CA	★★★★★	4/5

Compare this facility with the 3 closest →

All facilities in Baldwin Park →

Facility data as of CMS processing date 2026-08-01. CCN 555107.

The Care File

Visit checklist — Victoria Care Center

3541 Puente Avenue, Baldwin Park, CA 91706 · 6269621043

Health inspection rating 4/5 · CMS overall 5/5· Fines (3y): $0

Questions for the administrator:

☐ "Who completes resident assessments here, and how do you check them for accuracy?"
☐ "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 many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
☐ "Where do you post your daily staffing numbers, and can I see today's?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
☐ "How do you decide when a feeding tube is truly needed, and how do staff care for residents who have one?"
☐ "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 555107 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)