West Covina Medical Center D/P SNF

Name: West Covina Medical Center D/P SNF
Address: 725 S. ORANGE AVENUE, West Covina, CA, 91790, US
Telephone: 6263388481

725 S. Orange Avenue, West Covina, CA 91790 · Los Angeles County · 33 certified beds · avg 20 residents/day · certified since Oct 12, 1995

Part of chain: ROLLINS-NELSON HEALTHCARE MANAGEMENT (8 facilities, chain avg rating 2.4★)

4/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.49

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: 4/5

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 (35)

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
Jul 1, 2026	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
Dec 23, 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. · from a complaint
Dec 18, 2025	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.
Dec 18, 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 18, 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.
Dec 18, 2025	D · Potential for harm, one-off	The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way.
Dec 18, 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 18, 2025	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.
Dec 18, 2025	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.
Dec 18, 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.
Dec 18, 2025	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.
Dec 18, 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.
Dec 18, 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.
Oct 18, 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 18, 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 18, 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 18, 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.
Oct 18, 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.
Oct 18, 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.
Oct 18, 2024	D · Potential for harm, one-off	The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal.
Oct 18, 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 18, 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.
Oct 18, 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 18, 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.
Oct 18, 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.
Oct 18, 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.
Nov 22, 2023	E · Potential for harm, repeated	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.
Nov 22, 2023	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.
Nov 22, 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.
Nov 22, 2023	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.
Nov 22, 2023	E · Potential for harm, repeated	The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them.
Nov 22, 2023	E · Potential for harm, repeated	The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Nov 22, 2023	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.
Nov 22, 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.
Nov 22, 2023	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.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (13 → 11).

Year	Citations	Worst severity that year
2023	9	E
2024	13	E
2025	12	E
2026	1	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)	3.49	4.31	3.95	bottom 10% in California; bottom 36% in the U.S.
Registered Nurse hours	0.61	0.61	0.69	top 32% in California; top 46% in the U.S.
Weekend total nurse staffing	2.85	3.90	3.50	bottom 2% in California; bottom 23% in the U.S.
Weekend RN hours (not acuity-adjusted)	1.11	0.51	0.48	top 7% in California; top 4% in the U.S.
Total nursing staff turnover (%)	29.3	36.7	45.8	top 27% in California; top 13% 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 8.47, RN 1.49, weekend 6.93. 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: —/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
L a Downtown Medical Center LLC	Organization	5% or Greater Direct Ownership Interest	100%	03/01/2019
Besharat, Farid	Individual	Corporate Director	NOT APPLICABLE	03/15/2022
Besharat, Farid	Individual	Operational/Managerial Control	NOT APPLICABLE	03/01/2019
Besharat, Farid	Individual	ADP of the SNF	NOT APPLICABLE	03/01/2019
Francisco, Ann	Individual	Corporate Director	NOT APPLICABLE	03/01/2019
Francisco, Ann	Individual	Operational/Managerial Control	NOT APPLICABLE	03/01/2019
Francisco, Ann	Individual	ADP of the SNF	NOT APPLICABLE	03/01/2019
Nelson, William	Individual	Corporate Officer	NOT APPLICABLE	01/01/2023
Nelson, William	Individual	Operational/Managerial Control	NOT APPLICABLE	03/01/2019
Nelson, William	Individual	ADP of the SNF	NOT APPLICABLE	03/01/2019
Rollins, Vicki	Individual	Corporate Officer	NOT APPLICABLE	08/28/2017
Rollins, Vicki	Individual	Operational/Managerial Control	NOT APPLICABLE	03/01/2019
Siregar, Christopher	Individual	Corporate Director	NOT APPLICABLE	03/01/2019
Siregar, Christopher	Individual	Operational/Managerial Control	NOT APPLICABLE	03/01/2019
Siregar, Christopher	Individual	ADP of the SNF	NOT APPLICABLE	03/01/2019
West Covina Property Holding, LLC	Organization	5% or Greater Mortgage Interest	NOT APPLICABLE	03/01/2019
West Covina Property Holding, LLC	Organization	ADP of the SNF	NOT APPLICABLE	03/01/2019

Questions to ask on your visit

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

"When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
"How do you keep residents' medical records accurate, complete, and secure?"
"Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
"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 your staff protect residents' dignity in everyday care, like bathing and dressing?"
"If my family member's health suddenly changes, how quickly do you reassess them and update their care?"
"Who completes resident assessments here, and how do you check them for accuracy?"
"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
West Haven Healthcare	0.2 mi	West Covina, CA	★★★★☆	3/5
West Covina Healthcare Center	0.6 mi	West Covina, CA	★★★☆☆	3/5
Clara Baldwin Stocker Home for Women	0.7 mi	West Covina, CA	★★★☆☆	2/5
Victoria Care Center	0.7 mi	Baldwin Park, CA	★★★★★	4/5
Garden View Post Acute Rehabilitation	1.2 mi	Baldwin Park, CA	★★★★☆	3/5
Beacon Healthcare Center	1.7 mi	West Covina, CA	★★★★★	4/5
Coast Care Convalescent Center	1.9 mi	Baldwin Park, CA	★★★★☆	4/5
Sierra View Care Center	2.0 mi	Baldwin Park, CA	★★★★☆	3/5
The Rowland	2.4 mi	Covina, CA	★☆☆☆☆	1/5
Harvard Creek Post Acute	2.5 mi	Covina, CA	★★★★★	4/5

Compare this facility with the 3 closest →

All facilities in West Covina →

Facility data as of CMS processing date 2026-08-01. CCN 555649.

The Care File

Visit checklist — West Covina Medical Center D/P SNF

725 S. Orange Avenue, West Covina, CA 91790 · 6263388481

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

Questions for the administrator:

☐ "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
☐ "How do you keep residents' medical records accurate, complete, and secure?"
☐ "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
☐ "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 your staff protect residents' dignity in everyday care, like bathing and dressing?"
☐ "If my family member's health suddenly changes, how quickly do you reassess them and update their care?"
☐ "Who completes resident assessments here, and how do you check them for accuracy?"
☐ "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?"

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 555649 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)