Monrovia Gardens Healthcare Center
Nursing Home · Monrovia, CA
CMS certification number055367
Contact & location
615 W. Duarte RD.Monrovia, CA 91016
Los Angeles County
- Phone
- (626) 358-4547
- ZIP code
- 91016 – all care providers
Facility details
- Certified beds
- 96
- Residents per day
- 79.6 (83% occupied)
- Ownership
- For profit - Limited Liability company
- Legal name
- Ag Monrovia, LLC
- Chain
- Cambridge Healthcare Services (32 facilities, avg 2.5★)
- Medicare certified since
- December 31, 1971
- Participates in
- Medicare and Medicaid
- Council
- Resident council
CMS star ratings
Staffing
Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.
- Total nurse staffing
- 4.38 (state 4.52 · U.S. 3.86)
- Registered nurses (RN)
- 0.44 (state 0.67 · U.S. 0.69)
- Licensed practical nurses
- 1.23 (state 1.20 · U.S. 0.86)
- Nurse aides
- 2.71 (state 2.65 · U.S. 2.32)
- Weekend total
- 3.80 (state 4.09 · U.S. 3.42)
- Nursing staff turnover
- 50.5 (state 36.7 · U.S. 45.8)%
- RN turnover
- 50.0 (state 38.1 · U.S. 42.9)%
- Administrators who left
- 1 in the last year
Inspections
- Last standard inspection
- December 19, 2025
- Health deficiencies (last cycle)
- 30.0 (state 15.7 · U.S. 9.3)
- From complaints
- 15
- Citations on record (3 years)
- 73 health · 7 fire safety · includes actual harm
| Date | Citation | Severity | Status |
|---|---|---|---|
| 2026-06-23 | Ensure each resident’s drug regimen must be free from unnecessary drugs. F0757 · Pharmacy Service Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2026-06-25 |
| 2026-06-23 | Ensure that residents are fully informed and understand their health status, care and treatments. F0552 · Resident Rights Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2026-07-13 |
| 2026-06-04 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. F0676 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2026-06-05 |
| 2026-03-03 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. F0657 · Resident Assessment and Care Planning Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2026-03-23 |
| 2026-03-03 | Provide appropriate foot care. F0687 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2026-03-23 |
| 2026-03-03 | Provide safe, appropriate dialysis care/services for a resident who requires such services. F0698 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2026-03-23 |
| 2025-12-19 | 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. F0578 · Resident Rights Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2025-12-29 |
| 2025-12-19 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684 · Quality of Life and Care Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2025-12-29 |
| 2025-12-19 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755 · Pharmacy Service Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2025-12-29 |
| 2025-12-19 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812 · Nutrition and Dietary Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2025-12-29 |
| 2025-12-19 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. F0550 · Resident Rights Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-12-30 |
| 2025-12-19 | Not hire anyone with a finding of abuse, neglect, exploitation, or theft. F0606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-12-29 |
| 2025-12-19 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656 · Resident Assessment and Care Planning Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-12-29 |
| 2025-12-19 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. F0657 · Resident Assessment and Care Planning Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-12-29 |
| 2025-12-19 | Provide activities to meet all resident's needs. F0679 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-12-29 |
| 2025-12-19 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. F0686 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-12-29 |
| 2025-12-19 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-12-29 |
| 2025-12-19 | 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. F0693 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-12-29 |
| 2025-12-19 | Provide safe and appropriate respiratory care for a resident when needed. F0695 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-12-29 |
| 2025-12-19 | Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-12-29 |
| 2025-12-19 | Implement a program that monitors antibiotic use. F0881 · Infection Control Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-12-29 |
| 2025-10-31 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-11-18 |
| 2025-09-17 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. F0557 · Resident Rights Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-11-23 |
| 2025-09-03 | Provide care and assistance to perform activities of daily living for any resident who is unable. F0677 · Quality of Life and Care Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2025-09-24 |
| 2025-09-03 | Reasonably accommodate the needs and preferences of each resident. F0558 · Resident Rights Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-09-23 |
| 2025-09-03 | 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. F0808 · Nutrition and Dietary Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-09-23 |
| 2025-08-27 | Keep all essential equipment working safely. F0908 · Environmental Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2025-09-15 |
| 2025-08-05 | Reasonably accommodate the needs and preferences of each resident. F0558 · Resident Rights Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2025-08-27 |
| 2025-08-05 | Provide care and assistance to perform activities of daily living for any resident who is unable. F0677 · Quality of Life and Care Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2025-08-30 |
| 2025-08-05 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. F0867 · Administration Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2025-08-21 |
| 2025-07-09 | Reasonably accommodate the needs and preferences of each resident. F0558 · Resident Rights Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-07-11 |
| 2025-07-09 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. F0604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-06-27 |
| 2025-07-09 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-07-11 |
| 2025-05-13 | Reasonably accommodate the needs and preferences of each resident. F0558 · Resident Rights Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-05-14 |
| 2025-05-13 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. F0607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-05-14 |
| 2025-05-13 | Provide care and assistance to perform activities of daily living for any resident who is unable. F0677 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-05-14 |
| 2025-04-24 | Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2025-04-25 |
| 2025-04-24 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656 · Resident Assessment and Care Planning Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-05-13 |
| 2025-03-27 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. F0725 · Nursing and Physician Services Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2025-04-01 |
| 2025-03-27 | Keep residents' personal and medical records private and confidential. F0583 · Resident Rights Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-04-01 |
| 2025-03-27 | Provide care and assistance to perform activities of daily living for any resident who is unable. F0677 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-04-01 |
| 2025-03-27 | Provide safe, appropriate pain management for a resident who requires such services. F0697 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-04-01 |
| 2025-03-27 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. F0806 · Nutrition and Dietary Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-03-28 |
| 2025-03-27 | Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. F0807 · Nutrition and Dietary Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-03-28 |
| 2025-02-26 | 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. F0688 · Quality of Life and Care Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2025-03-20 |
| 2025-02-26 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. F0842 · Resident Assessment and Care Planning Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2025-03-20 |
| 2025-02-26 | 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. F0584 · Resident Rights Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-03-21 |
| 2025-02-10 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656 · Resident Assessment and Care Planning Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-02-12 |
| 2025-01-24 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies · complaint inspection |
G Actual harm |
Corrected 2025-02-20 |
| 2025-01-24 | Provide care and assistance to perform activities of daily living for any resident who is unable. F0677 · Quality of Life and Care Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2025-02-12 |
Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results
Fines & penalties
No federal fines or payment denials in the last three years.
Ownership & management
| Name | Role | Since |
|---|---|---|
| Ag Facilities Operations, LLC (organization) | 5%+ Direct Ownership Interest · 100% | |
| Ira E Smedra Living Trust (organization) | 5%+ Indirect Ownership Interest · 48% | |
| Win Win Enterprises, LLC (organization) | 5%+ Indirect Ownership Interest · 48% | |
| 615 W. Duarte, LLC (organization) | Administrator · NOT APPLICABLE | |
| Balacuit, Donald (individual) | Administrator · NOT APPLICABLE | |
| Butenko, Julie (individual) | Administrator · NOT APPLICABLE | |
| Cambridge Healthcare Services LLC (organization) | Administrator · NOT APPLICABLE | |
| Capela, Heidi (individual) | Administrator · NOT APPLICABLE | |
| Hassell, Lance (individual) | Administrator · NOT APPLICABLE | |
| Lutz, Linda (individual) | Administrator · NOT APPLICABLE | |
| Salazar, Paulina (individual) | Administrator · NOT APPLICABLE | |
| Smedra, Ira (individual) | Administrator · NOT APPLICABLE | |
| Sohal, Jaspal (individual) | Administrator · NOT APPLICABLE | |
| Vidales, Miguel (individual) | Administrator · NOT APPLICABLE | |
| Win Win Enterprises, LLC (organization) | Administrator · NOT APPLICABLE | |
| Wintner, Jacob (individual) | Administrator · NOT APPLICABLE | |
| Wintner, Jacob (individual) | Corporate Officer · NOT APPLICABLE | |
| Sohal, Jaspal (individual) | Managing Control - Governing Body · NOT APPLICABLE | |
| Vidales, Miguel (individual) | Managing Control - Governing Body · NOT APPLICABLE | |
| Balacuit, Donald (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Butenko, Julie (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Cambridge Healthcare Services LLC (organization) | Operational/managerial Control · NOT APPLICABLE | |
| Capela, Heidi (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Cruz, Hayley (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Hassell, Lance (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Lutz, Linda (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Salazar, Paulina (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Smedra, Ira (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Sohal, Jaspal (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Vidales, Miguel (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Wintner, Jacob (individual) | Operational/managerial Control · NOT APPLICABLE |
Frequently asked questions
What is the rating of Monrovia Gardens Healthcare Center?
Monrovia Gardens Healthcare Center has a 1-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 3.2-star average in California.
How many beds does Monrovia Gardens Healthcare Center have?
It has 96 certified beds and cares for about 80 residents per day.
Has Monrovia Gardens Healthcare Center been fined?
CMS lists no federal fines or payment denials in the last three years.
Who owns Monrovia Gardens Healthcare Center?
It is part of Cambridge Healthcare Services and is classified as for profit - limited liability company. See the ownership table above for all owners and managers reported to CMS.
What is the phone number of Monrovia Gardens Healthcare Center?
(626) 358-4547. The facility is located at 615 W. Duarte RD., Monrovia, CA 91016.
Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.