Monte Vista Healthcare Center
802 Buena Vista Street · Duarte, CA · 91010 · 6263598141
69 certified beds For profit - Corporation Chain: Cambridge Healthcare Services
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results are getting worse cycle over cycle, not better.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 3 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 4.19 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.36 | 0.55–0.75 |
| Weekend hours / resident-day | 3.71 | ≈ weekday level |
| Nursing turnover / year | 44% | median 45% |
| Fines (3-yr window) | 2 · $5,244 |
Inspection citations (45 in the current record)
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Potential for harm · E March 4, 2026 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected March 27, 2026 · Resident Assessment and Care Planning
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Potential for harm · D March 4, 2026 · found via complaint
Provide and implement an infection prevention and control program.
Corrected March 27, 2026 · Infection Control
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Potential for harm · D February 17, 2026 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected March 6, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D January 9, 2026 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected February 5, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D January 9, 2026 · found via complaint
Respond appropriately to all alleged violations.
Corrected February 5, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D January 9, 2026 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected February 5, 2026 · Quality of Life and Care
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Potential for harm · D July 23, 2025 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected August 15, 2025 · Nutrition and Dietary
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Potential for harm · D July 23, 2025 · found via complaint
Dispose of garbage and refuse properly.
Corrected August 15, 2025 · Nutrition and Dietary
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Potential for harm · D February 21, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected March 17, 2025 · Resident Rights
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Potential for harm · D February 21, 2025
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected March 17, 2025 · Resident Rights
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Potential for harm · E February 21, 2025
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.
Corrected March 17, 2025 · Resident Rights
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Potential for harm · D February 21, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected March 17, 2025 · Resident Assessment and Care Planning
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Potential for harm · E February 21, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected March 17, 2025 · Quality of Life and Care
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Potential for harm · E February 21, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected March 17, 2025 · Quality of Life and Care
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Potential for harm · D February 21, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected March 17, 2025 · Quality of Life and Care
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Potential for harm · D February 21, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected March 17, 2025 · Quality of Life and Care
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Potential for harm · D February 21, 2025
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.
Corrected March 17, 2025 · Quality of Life and Care
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Potential for harm · E February 21, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected March 17, 2025 · Quality of Life and Care
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Potential for harm · E February 21, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected March 17, 2025 · Pharmacy Service
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Potential for harm · E February 21, 2025
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.
Corrected March 17, 2025 · Pharmacy Service
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Potential for harm · E February 21, 2025
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.
Corrected March 17, 2025 · Nutrition and Dietary
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Potential for harm · D February 21, 2025
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected March 17, 2025 · Nutrition and Dietary
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Potential for harm · E February 21, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected March 17, 2025 · Nutrition and Dietary
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Potential for harm · E February 21, 2025
Provide and implement an infection prevention and control program.
Corrected March 17, 2025 · Infection Control
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Potential for harm · D February 21, 2025
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected March 17, 2025 · Environmental
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| June 26, 2023 | Fine | $2,797 |
| June 20, 2023 | Fine | $2,447 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 055817 · certified since September 5, 1967. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.