West Covina Healthcare Center
850 S. Sunkist Ave., West Covina, CA 91790 · Los Angeles County · 97 certified beds · avg 90 residents/day · certified since Dec 31, 1971
Part of chain: CAMBRIDGE HEALTHCARE SERVICES (32 facilities, chain avg rating 2.5★)
3/5
Health inspection rating (on-site)
3
Serious findings on record
$78,978
Fines, last 3 years
3.84
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 · Mar 28, 2024 · F-0760 · triggered by a complaint
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.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
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: Apr 30, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 31, 2024 · F-0656 · triggered by a complaint
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.
Why it matters: Without a complete, working care plan, important needs can slip through the cracks and no one is accountable for results.
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: Feb 23, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 13, 2023 · F-0686
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.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
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: Nov 17, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (50)
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 7, 2026 | 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 |
| Apr 23, 2026 | 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 |
| Jan 2, 2026 | 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 5, 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. |
| Dec 5, 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 5, 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 5, 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. |
| Dec 5, 2025 | 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. |
| Dec 5, 2025 | D · Potential for harm, one-off | 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 5, 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. |
| Dec 5, 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 5, 2025 | 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. |
| Dec 5, 2025 | B · Minimal risk, 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. |
| Dec 5, 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. |
| Jul 25, 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. · from a complaint |
| Dec 27, 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 3, 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. |
| Oct 3, 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. |
| Oct 3, 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. |
| Oct 3, 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 3, 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 3, 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. |
| Oct 3, 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 3, 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. |
| Oct 3, 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 3, 2024 | 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. |
| Oct 3, 2024 | 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. |
| Oct 3, 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. |
| Jul 3, 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 24, 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 |
| Jun 7, 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. · from a complaint |
| May 6, 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. · from a complaint |
| May 6, 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. · from a complaint |
| Mar 28, 2024 | ▲ G · Actual 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. · from a complaint |
| Mar 28, 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. · from a complaint |
| Mar 28, 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 |
| Jan 31, 2024 | ▲ G · Actual 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 |
| Jan 31, 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. · from a complaint |
| Nov 28, 2023 | 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 |
| Oct 13, 2023 | ▲ G · Actual 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 13, 2023 | 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. |
| Oct 13, 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. |
| Oct 13, 2023 | 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. |
| Oct 13, 2023 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Oct 13, 2023 | 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. |
| Oct 13, 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. |
| Oct 13, 2023 | D · Potential for harm, one-off | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Oct 13, 2023 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Oct 13, 2023 | 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 7, 2023 | 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 |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (12 → 11).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 12 | 1 | G ▲ |
| 2024 | 23 | 2 | G ▲ |
| 2025 | 12 | 0 | E |
| 2026 | 3 | 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)
3 fines totaling $78,978, plus 2 Medicare payment denial periods.
| Date | Type | Amount / length |
|---|---|---|
| Mar 28, 2024 | Fine | $29,816 |
| Mar 28, 2024 | Payment Denial | 4 days from Apr 26, 2024 |
| Jan 31, 2024 | Fine | $14,211 |
| Oct 13, 2023 | Fine | $34,951 |
| Oct 13, 2023 | Payment Denial | 6 days from Nov 11, 2023 |
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) | 3.84 | 4.31 | 3.95 | bottom 30% in California; top 46% in the U.S. |
| Registered Nurse hours | 0.47 | 0.61 | 0.69 | bottom 48% in California; bottom 33% in the U.S. |
| Weekend total nurse staffing | 3.47 | 3.90 | 3.50 | bottom 28% in California; top 43% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.36 | 0.51 | 0.48 | bottom 48% in California; bottom 45% in the U.S. |
| Total nursing staff turnover (%) | 40.4 | 36.7 | 45.8 | bottom 37% in California; top 37% in the U.S. |
| RN turnover (%) | 50.0 | 38.1 | 42.9 | bottom 29% in California; bottom 39% 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 4.01, RN 0.49, weekend 3.63. 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 |
|---|---|---|---|---|
| Ag Facilities Operations, LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 08/11/2003 |
| Ira E Smedra Living Trust | Organization | 5% or Greater Indirect Ownership Interest | 48% | 08/11/2017 |
| Win Win Enterprises, LLC | Organization | 5% or Greater Indirect Ownership Interest | 48% | 08/11/2003 |
| Amanda Lee Sorensen Trust | Organization | ADP of the SNF | NOT APPLICABLE | 07/02/2007 |
| Baltazar, Eileen | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/07/2022 |
| Baltazar, Eileen | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/07/2022 |
| Baltazar, Eileen | Individual | ADP of the SNF | NOT APPLICABLE | 11/12/2025 |
| Butenko, Julie | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/24/2023 |
| Butenko, Julie | Individual | ADP of the SNF | NOT APPLICABLE | 07/24/2023 |
| Cambridge Healthcare Services LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 10/01/2013 |
| Cambridge Healthcare Services LLC | Organization | ADP of the SNF | NOT APPLICABLE | 11/12/2025 |
| Capela, Heidi | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/03/2023 |
| Capela, Heidi | Individual | ADP of the SNF | NOT APPLICABLE | 04/03/2023 |
| Chapeaux Enterprises | Organization | ADP of the SNF | NOT APPLICABLE | 07/02/2007 |
| Cory Ann Sorensen | Organization | ADP of the SNF | NOT APPLICABLE | 07/02/2007 |
| Hassell, Lance | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/25/2022 |
| Hassell, Lance | Individual | ADP of the SNF | NOT APPLICABLE | 04/25/2022 |
| Lutz, Linda | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/01/2012 |
| Lutz, Linda | Individual | ADP of the SNF | NOT APPLICABLE | 02/01/2012 |
| Manojo, Sheila | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/11/2024 |
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 systems do you use to prevent medication errors, and what happens when one occurs?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "If I ask for a copy of my family member's records, how quickly will I get them and what does it cost?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "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?"
- "How do you explain health changes and treatment options to residents and their families?"
- "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 |
|---|---|---|---|---|---|
| Victoria Care Center | 0.5 mi | Baldwin Park, CA | ★★★★★ | 4/5 | |
| West Covina Medical Center D/P SNF | 0.6 mi | West Covina, CA | ★★★★☆ | 4/5 | |
| Garden View Post Acute Rehabilitation | 0.6 mi | Baldwin Park, CA | ★★★★☆ | 3/5 | |
| West Haven Healthcare | 0.6 mi | West Covina, CA | ★★★★☆ | 3/5 | |
| Clara Baldwin Stocker Home for Women | 1.2 mi | West Covina, CA | ★★★☆☆ | 2/5 | |
| Beacon Healthcare Center | 1.4 mi | West Covina, CA | ★★★★★ | 4/5 | |
| Coast Care Convalescent Center | 1.6 mi | Baldwin Park, CA | ★★★★☆ | 4/5 | |
| Sierra View Care Center | 1.8 mi | Baldwin Park, CA | ★★★★☆ | 3/5 | |
| The Rowland | 2.9 mi | Covina, CA | ★☆☆☆☆ | 1/5 | |
| Harvard Creek Post Acute | 3.1 mi | Covina, CA | ★★★★★ | 4/5 | |
| Eastland Subacute and Rehabilitation Center | 3.4 mi | El Monte, CA | ★★☆☆☆ | 2/5 | |
| Penn Mar Healthcare Center | 3.5 mi | El Monte, CA | ★★☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 055992.