Monrovia Gardens Healthcare Center
615 W. Duarte Rd., Monrovia, CA 91016
Monrovia Gardens Healthcare Center is a nursing home in Monrovia, California. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating1 of 5
- Last standard health inspectionDecember 19, 2025 (10 months ago)
- Health citations since October 11, 2023104 (California average 50)
- Fines in the past three yearsNone listed by CMS
- CMS flagsNone listed by CMS
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of July 29, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Health inspection on July 15, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on July 17, 2026.
CMS has cited this home for F0656 7 times since 2023.
Health inspection on July 8, 2026
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on July 10, 2026.
CMS has cited this home for F0677 6 times since 2025.
Citation F0803. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
CMS lists it as corrected on July 10, 2026.
CMS has cited this home for F0803 2 times since 2024.
Citation F0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on July 10, 2026.
CMS has cited this home for F0919 2 times since 2024.
Health inspection on June 23, 2026
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0757. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on June 25, 2026.
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on July 13, 2026.
Health inspection on June 4, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0676. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0676 2 times since 2024.
Health inspection on March 3, 2026
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0657. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on March 23, 2026.
CMS has cited this home for F0657 3 times since 2023.
Citation F0687. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate foot care.
CMS lists it as corrected on March 23, 2026.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on March 23, 2026.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
Health inspection on December 19, 2025
15 citationsCMS lists this as a standard inspection.
Show the 15 citations
Citation F0578. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
CMS lists it as corrected on December 29, 2025.
CMS has cited this home for F0578 2 times since 2024.
Citation F0684. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on December 29, 2025.
CMS has cited this home for F0684 5 times since 2024.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on December 29, 2025.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on December 29, 2025.
CMS has cited this home for F0812 3 times since 2023.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on December 30, 2025.
CMS has cited this home for F0550 4 times since 2023.
Citation F0606. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
CMS lists it as corrected on December 29, 2025.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on December 29, 2025.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on December 29, 2025.
Citation F0679. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on December 29, 2025.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on December 29, 2025.
CMS has cited this home for F0686 2 times since 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on December 29, 2025.
CMS has cited this home for F0689 2 times since 2025.
Citation F0693. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
CMS lists it as corrected on December 29, 2025.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on December 29, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on December 29, 2025.
CMS has cited this home for F0880 5 times since 2023.
Citation F0881. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Implement a program that monitors antibiotic use.
CMS lists it as corrected on December 29, 2025.
Fire safety inspection on December 19, 2025
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on December 19, 2025.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on December 19, 2025.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on December 19, 2025.
CMS has cited this home for K0918 2 times since 2024.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on December 19, 2025.
CMS has cited this home for K0353 2 times since 2024.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on December 19, 2025.
CMS has cited this home for K0321 3 times since 2023.
Citation K0342. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
CMS lists it as corrected on December 19, 2025.
Citation K0351. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on December 19, 2025.
CMS update of November 20, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Health inspection on October 31, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on November 18, 2025.
CMS has cited this home for F0609 2 times since 2023.
Health inspection on September 17, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0557. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
CMS lists it as corrected on November 23, 2025.
Health inspection on September 3, 2025
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0677. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on September 24, 2025.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on September 23, 2025.
CMS has cited this home for F0558 5 times since 2024.
Citation F0808. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
CMS lists it as corrected on September 23, 2025.
Health inspection on August 27, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0908. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep all essential equipment working safely.
CMS lists it as corrected on September 15, 2025.
Health inspection on August 5, 2025
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0558. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on August 27, 2025.
Citation F0677. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on August 30, 2025.
Citation F0867. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS lists it as corrected on August 21, 2025.
CMS update of July 30, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Health inspection on July 9, 2025
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on July 11, 2025.
Citation F0604. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
CMS lists it as corrected on June 27, 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 11, 2025.
Health inspection on May 13, 2025
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on May 14, 2025.
Citation F0607. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on May 14, 2025.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on May 14, 2025.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
Health inspection on April 24, 2025
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 25, 2025.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on May 13, 2025.
Health inspection on March 27, 2025
6 citationsCMS lists this as a complaint inspection.
Show the 6 citations
Citation F0725. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on April 1, 2025.
CMS has cited this home for F0725 4 times since 2024.
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on April 1, 2025.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on April 1, 2025.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on April 1, 2025.
Citation F0806. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS lists it as corrected on March 28, 2025.
Citation F0807. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
CMS lists it as corrected on March 28, 2025.
Health inspection on February 26, 2025
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0688. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
CMS lists it as corrected on March 20, 2025.
CMS has cited this home for F0688 2 times since 2024.
Citation F0842. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on March 20, 2025.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS lists it as corrected on March 21, 2025.
CMS update of February 26, 2025
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
CMS abuse icon
CMS removed its abuse icon from this home.
Health inspection on February 10, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on February 12, 2025.
Health inspection on January 24, 2025
7 citationsCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
227 of 1,165 California homes (19%) got a citation at the actual harm level in 2025.
Show the 7 citations
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on February 20, 2025.
Citation F0677. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on February 12, 2025.
Citation F0725. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on January 27, 2025.
Citation F0576. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents have reasonable access to and privacy in their use of communication methods.
CMS lists it as corrected on January 29, 2025.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on January 29, 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on February 20, 2025.
Citation F0726. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
CMS lists it as corrected on January 29, 2025.
Health inspection on December 31, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0725. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on January 2, 2025.
Health inspection on December 24, 2024
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on January 14, 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on December 26, 2024.
Health inspection on November 25, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on November 28, 2024.
Health inspection on October 31, 2024
18 citationsCMS lists this as a standard inspection.
Show the 18 citations
Citation F0558. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on October 31, 2024.
Citation F0578. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
CMS lists it as corrected on November 18, 2024.
Citation F0684. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on November 20, 2024.
Citation F0686. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on November 20, 2024.
Citation F0690. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on November 20, 2024.
CMS has cited this home for F0690 2 times since 2023.
Citation F0725. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on November 5, 2024.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on November 4, 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on November 15, 2024.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on November 18, 2024.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on November 18, 2024.
CMS has cited this home for F0580 2 times since 2024.
Citation F0625. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
CMS lists it as corrected on November 20, 2024.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on November 19, 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on November 24, 2024.
Citation F0676. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
CMS lists it as corrected on November 18, 2024.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on November 15, 2024.
CMS has cited this home for F0692 2 times since 2023.
Citation F0790. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide routine and 24-hour emergency dental care for each resident.
CMS lists it as corrected on November 19, 2024.
Citation F0803. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
CMS lists it as corrected on November 1, 2024.
Citation F0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on November 19, 2024.
Fire safety inspection on October 31, 2024
6 citationsCMS lists this as a standard inspection.
Show the 6 citations
Citation E0041. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Implement emergency and standby power systems.
CMS lists it as corrected on November 30, 2024.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on November 30, 2024.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on November 30, 2024.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on November 30, 2024.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on November 30, 2024.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on November 30, 2024.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of September 26, 2024
CMS abuse icon
CMS added its abuse icon to this home.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
Health inspection on June 21, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on June 27, 2024.
Health inspection on May 29, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on August 2, 2024.
Health inspection on May 9, 2024
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0882. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
CMS lists it as corrected on May 10, 2024.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
CMS lists it as corrected on May 15, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 9, 2024.
CMS update of April 25, 2024
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Health inspection on October 19, 2023
17 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 17 citations
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS lists it as corrected on November 14, 2023.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on November 14, 2023.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on November 14, 2023.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on November 14, 2023.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on November 14, 2023.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on November 14, 2023.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on November 14, 2023.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on November 14, 2023.
Citation F0685. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assist a resident in gaining access to vision and hearing services.
CMS lists it as corrected on November 14, 2023.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on November 14, 2023.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on November 14, 2023.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on November 14, 2023.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on November 14, 2023.
Citation F0770. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely, quality laboratory services/tests to meet the needs of residents.
CMS lists it as corrected on November 14, 2023.
Citation F0773. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
CMS lists it as corrected on November 14, 2023.
Citation F0825. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or get specialized rehabilitative services as required for a resident.
CMS lists it as corrected on November 14, 2023.
Citation F0837. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
CMS lists it as corrected on November 14, 2023.
Fire safety inspection on October 19, 2023
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation K0321. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on November 11, 2023.
Citation K0341. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install a fire alarm system that can be heard throughout the facility.
CMS lists it as corrected on November 11, 2023.
Health inspection on October 11, 2023
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0609. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on October 25, 2023.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 2 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (626) 358-4547
- Last standard health inspection
- December 19, 2025 (10 months ago)
- Certified beds
- 96
- Residents per day, on average
- 82.1
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Ag Monrovia, LLC
- Chain
- Cambridge Healthcare Services
- Takes part in
- Medicare and Medicaid
More health citations than the California average (104 vs 50).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- AG FACILITIES OPERATIONS, LLC5% or greater direct ownership interest · 100% · since 08/11/2003
- IRA E SMEDRA LIVING TRUST5% or greater indirect ownership interest · 48% · since 08/11/2003
- WIN WIN ENTERPRISES, LLC5% or greater indirect ownership interest · 48% · since 08/11/2003
- CAMBRIDGE HEALTHCARE SERVICES LLCOperational/managerial control · not applicable · since 10/01/2013
- BALACUIT, DONALDOperational/managerial control · not applicable · since 04/18/2024
Show 10 more
- BUTENKO, JULIEOperational/managerial control · not applicable · since 07/24/2023
- CAPELA, HEIDIOperational/managerial control · not applicable · since 04/03/2023
- CRUZ, HAYLEYOperational/managerial control · not applicable · since 04/01/2025
- HASSELL, LANCEOperational/managerial control · not applicable · since 04/25/2022
- LUTZ, LINDAOperational/managerial control · not applicable · since 02/01/2012
- SALAZAR, PAULINAOperational/managerial control · not applicable · since 12/14/2020
- SMEDRA, IRAOperational/managerial control · not applicable · since 08/11/2003
- SOHAL, JASPALOperational/managerial control · not applicable · since 10/22/2024
- VIDALES, MIGUELOperational/managerial control · not applicable · since 03/01/2021
- WINTNER, JACOBOperational/managerial control · not applicable · since 08/11/2003
Questions
When was Monrovia Gardens Healthcare Center last inspected?
CMS lists December 19, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Monrovia Gardens Healthcare Center have?
CMS lists 104 health citations since October 11, 2023. CMS also calls these deficiencies.
Has Monrovia Gardens Healthcare Center been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Monrovia Gardens Healthcare Center?
Its CMS overall star rating is 1 of 5.
Is Monrovia Gardens Healthcare Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.