Madera Post Acute Center
El Monte, Los Angeles County, California · CCN 055141 · For-profit (Corporation) · part of The Ensign Group (342 facilities, chain average 3.2 stars)
CMS rates Madera Post Acute Center 1 of 5 overall as of August 2026. 148 certified beds, 134 residents a day on average. 70 citations on record from the current inspection cycles, 1 at immediate jeopardy; 2 fines totalling $29,517.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★☆☆☆☆ 1 of 5 |
|---|---|
| Health inspections | ★☆☆☆☆ 1 of 5 |
| Staffing | ★★★☆☆ 3 of 5 |
| Quality measures | ★★★★☆ 4 of 5 |
| Quality: long-stay / short-stay | 5 / 4 of 5 |
Staffing
| Total nurse staffing | 3.98921 hours per resident per day |
|---|---|
| Registered nurses | 0.33972 hours per resident per day |
| Weekend total | 3.43646 hours per resident per day |
| Nursing staff turnover | 49.7% (registered nurses 35.7%) |
| Administrators who left | 0 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-05-15 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-06-10 |
| 2026-05-15 complaint survey |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-06-10 |
| 2026-05-15 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-06-09 |
| 2026-04-23 complaint survey |
Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · tag F0558 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-15 |
| 2026-04-23 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-14 |
| 2026-04-23 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-11 |
| 2026-04-23 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-14 |
| 2026-04-08 complaint survey |
Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · tag F0558 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-01 |
| 2026-03-16 complaint survey |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-04-02 |
| 2026-03-16 complaint survey |
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Resident Rights Deficiencies · tag F0557 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-02 |
| 2026-03-16 complaint survey |
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. Pharmacy Service Deficiencies · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-02 |
| 2026-03-16 complaint survey |
Have policies on smoking. Environmental Deficiencies · tag F0926 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-02 |
| 2026-01-28 complaint survey |
Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-14 |
| 2026-01-06 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-01-30 |
| 2026-01-06 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-01-30 |
| 2026-01-06 complaint survey |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-01-30 |
| 2025-08-21 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-09-12 |
| 2025-07-10 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
K Immediate jeopardy to resident health or safety; pattern | Deficient, Provider has date of correction 2025-07-24 |
| 2025-07-10 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-07-30 |
| 2025-07-10 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-07-30 |
| 2025-07-10 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-07-30 |
| 2025-07-10 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-07-25 |
| 2025-07-10 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-07-30 |
| 2025-07-10 | 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. Resident Rights Deficiencies · tag F0584 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-30 |
| 2025-07-10 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-30 |
| 2025-07-10 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · tag F0700 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-30 |
| 2025-07-10 | Provide special eating equipment and utensils for residents who need them and appropriate assistance. Nutrition and Dietary Deficiencies · tag F0810 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-30 |
| 2025-07-10 | Keep all essential equipment working safely. Environmental Deficiencies · tag F0908 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-30 |
| 2025-07-10 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · tag F0732 |
B No actual harm, with potential for minimal harm; pattern | Deficient, Provider has date of correction 2025-07-30 |
| 2025-04-07 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-05-01 |
| 2025-03-19 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-09 |
| 2025-02-05 complaint survey |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-03 |
| 2025-02-05 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-03 |
| 2024-12-16 complaint survey |
Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-01-07 |
| 2024-10-10 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-01 |
| 2024-10-09 complaint survey |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-28 |
| 2024-07-19 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · tag F0558 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-06 |
| 2024-07-19 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · tag F0676 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-05 |
| 2024-07-19 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-08 |
| 2024-07-19 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · tag F0690 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-08 |
| 2024-07-19 | 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. Quality of Life and Care Deficiencies · tag F0693 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-08 |
| 2024-07-19 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · tag F0700 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-12 |
| 2024-07-19 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-12 |
| 2024-07-19 | 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. Resident Rights Deficiencies · tag F0578 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-07 |
| 2024-07-19 | 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. Quality of Life and Care Deficiencies · tag F0688 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-09 |
| 2024-07-19 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-08 |
| 2024-07-19 | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies · tag F0849 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-08 |
| 2024-07-19 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · tag F0732 |
B No actual harm, with potential for minimal harm; pattern | Deficient, Provider has date of correction 2024-08-07 |
| 2024-05-17 complaint survey |
Provide for the safe, appropriate administration of IV fluids for a resident when needed. Quality of Life and Care Deficiencies · tag F0694 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-17 complaint survey |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-14 |
| 2024-03-08 complaint survey |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · tag F0725 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-27 |
| 2024-03-08 complaint survey |
Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · tag F0919 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-27 |
| 2021-10-21 | 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. Resident Rights Deficiencies · tag F0578 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2021-12-01 |
| 2021-10-21 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2021-12-01 |
| 2021-10-21 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2021-12-01 |
| 2021-10-21 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · tag F0552 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-01 |
| 2021-10-21 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · tag F0558 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-01 |
| 2021-10-21 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · tag F0583 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-01 |
| 2021-10-21 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-01 |
| 2021-10-21 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-01 |
| 2021-10-21 | Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · tag F0685 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-01 |
| 2021-10-21 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-01 |
| 2021-10-21 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-01 |
| 2021-10-21 | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0691 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-01 |
| 2021-10-21 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0697 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-01 |
| 2021-10-21 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-01 |
| 2021-10-21 | 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. Pharmacy Service Deficiencies · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-01 |
| 2021-10-21 | Provide or get specialized rehabilitative services as required for a resident. Quality of Life and Care Deficiencies · tag F0825 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-01 |
| 2021-10-21 | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies · tag F0849 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-01 |
| 2021-10-21 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · tag F0881 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-01 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2025-07-10 | Fine | $13,319 |
| 2024-05-17 | Fine | $16,198 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Ensign Services Inc. Organization | adp of the snf | — | 2022-11-01 |
| Twomagnets LLC Organization | adp of the snf | — | 2025-08-18 |
| Twomagnets LLC Organization | operational/managerial control | — | 2023-02-01 |
| Liu, John Individual | adp of the snf | — | 2023-02-01 |
| Yamak, Najib Individual | adp of the snf | — | 2023-02-01 |
| Willits, Adam Individual | corporate director | — | 2023-02-01 |
| Burnam, Soon Individual | corporate officer | — | 2022-11-08 |
| Gamero, Alicia Individual | corporate officer | — | 2023-02-01 |
| Keetch, Chad Individual | corporate officer | — | 2011-03-01 |
| Sato, Ami Individual | corporate officer | — | 2024-09-09 |
| Port, Barry Individual | individual is an owner, partner or trustee of any adp of the snf | — | 2025-06-30 |
| Liu, John Individual | managing control - governing body | — | 2023-02-01 |
| Yamak, Najib Individual | managing control - governing body | — | 2023-02-01 |
| Liu, John Individual | operational/managerial control | — | 2023-02-01 |
| Yamak, Najib Individual | operational/managerial control | — | 2023-02-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Madera Post Acute Center.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Los Angeles County.