Freedom Village Healthcare Center
Lake Forest, California
Skilled nursing facility in Lake Forest, CA with 52 certified beds and a 5-star CMS overall rating.
Freedom Village Healthcare Center is a skilled nursing facility in Lake Forest, California (Orange County), with 52 Medicare/Medicaid-certified beds.
Address: 23442 El Toro Road, Lake Forest, CA 92630. Phone: (949) 472-0277.
Ownership: For profit - Partnership. Certified for Medicare and Medicaid. Part of a continuing care retirement community. Automatic sprinkler systems in all required areas. Has a resident council.
CMS Five-Star ratings (source: Medicare Care Compare): overall 5 of 5, health inspections 3, staffing 5, quality measures 5.
Levels of care
- Skilled nursing
Facility details
- Street address
- 23442 El Toro Road
- City
- Lake Forest
- State
- California
- ZIP code
- 92630
- Phone
- (949) 472-0277
- Levels of care
- Skilled nursing
- Payment options accepted
- Medicare, Medicaid
- Cms Ccn
- 555391
- County
- Orange
- Ownership Type
- For profit - Partnership
- Provider Type
- Medicare and Medicaid
- Certified Beds
- 52
- Avg Daily Residents
- 40.1
- Continuing Care Community
- Yes
- Resident Family Council
- Resident
- Sprinklers All Areas
- Yes
- Medicare Medicaid Approved Date
- 1989-10-26
- Overall Rating
- 5
- Health Inspection Rating
- 3
- Staffing Rating
- 5
- Quality Measure Rating
- 5
- Total Nurse Hours Per Resident Day
- 5.02539
- Rn Hours Per Resident Day
- 0.69642
- Latitude
- 33.6226
- Longitude
- -117.7
Medicare & Medicaid quality data
Published by the Centers for Medicare & Medicaid Services (CMS) [1] , data as of October 1, 2026. CMS ID 555391. Ratings compare this home with other nursing homes; they are not a pass or fail.
How does it compare in Lake Forest? · Lowest-rated in California
CMS overall rating
5 / 5
Much above average- Certified beds
- 52
- Residents per day
- 40
- Ownership
- For profit - Partnership
- Health citations (latest)
- 17
- Fines
- 0
Star ratings
CMS rates every certified nursing home from 1 to 5 stars in three areas and combines them into an overall rating. The ratings compare homes with each other: 5 is much above average, 3 is average, 1 is much below average.
Overall rating
Much above averageThe headline score, from 1 to 5 stars.
✓ Better than the state average. State 3.2 · National 3.0
How is this scored?
Three steps: start with the health inspection stars; add one star if staffing is 5 stars (subtract one if it is 1 star); then add one star if quality measures are 5 stars (subtract one if 1 star). It never goes above 5 or below 1, and a home with 1 health inspection star can gain at most one star from the other two. It compares homes with each other; it is not a pass/fail grade. [11]
Health inspections
Above averageHow the home did in recent state inspections and complaint investigations.
✓ Better than the state average. State 2.8 · National 2.8
How is this scored?
Based on the two most recent annual inspections plus 36 months of complaint and infection-control inspections, and on how many revisits were needed to confirm fixes. Each citation is weighted by scope and severity. Homes are then ranked within their own state: the best 10% (lowest scores) earn 5 stars, the middle 70% earn 2, 3 or 4 stars in equal shares, and the worst 20% earn 1 star. [11]
Staffing
Above averageHow many nurses care for each resident, and how stable the nursing team is.
✓ Better than the state average. State 3.3 · National 3.0
How is this scored?
Six measures: three of staffing level (total nurse, registered nurse and weekend nurse hours per resident per day, adjusted for how much care residents need) and three of turnover (nursing staff, RNs and administrators). The hours come from payroll records submitted to CMS each quarter; turnover uses six quarters of that data. [11]
Quality measures
Much above averageHow residents are actually doing.
✓ Better than the state average. State 4.2 · National 3.7
How is this scored?
Scores 15 quality measures drawn from resident assessments (the Minimum Data Set) and Medicare claims, such as falls with major injury, pressure ulcers, rehospitalizations and medication use. Long-stay and short-stay residents are rated separately and combined. [11]
This home State average National average
- Long-stay quality
- Residents who live in the home: outcomes such as falls, pressure ulcers and medication use.
- Short-stay quality
- Residents staying for rehab or recovery: outcomes such as rehospitalization and regaining function.
Flags CMS attaches to this home
How to read the numbers on this page
- Star ratings — 1 to 5 (no stars = not rated)
- 5 is much above average and 1 is much below average, compared with other nursing homes. A home with too little data may have no rating.
- Health inspection score — 0 and up, lower is better
- Points added up from citations (see the scope and severity grid) and revisits. 0 means a clean record; the state table shows which scores earn which stars.
- Quality measure percentages — 0 to 100%
- The share of residents with an outcome, such as a fall with major injury. For most measures a lower percentage is better; for vaccination measures a higher percentage is better.
- Nurse hours per resident per day — Hours, higher is better
- Paid nursing time divided by residents. For example 4.0 means each resident gets about four hours of nursing care a day, shared across all shifts.
- Staff turnover — 0 to 100%, lower is better
- The share of nursing staff who left during the year. High turnover can mean less continuity of care.
- Case-mix index — Around 1.0 is typical
- How much care the residents need. Above 1 means sicker or more dependent residents who need more staff time.
- Fines — Dollars; payment denials in days
- Penalties CMS imposed for serious or repeated problems. A payment denial stops Medicare/Medicaid payment for new admissions.
Sources: Nursing Home Provider Information [1] ; Nursing Home State & National Averages [9] ; Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users' Guide [11]
Staffing & turnover
More nursing time per resident and a steadier team are both signs of better care. Hours come from payroll records the home submits to CMS each quarter.
Nurse hours per resident per day, by role
A resident's day is 24 hours; this is how much paid nursing time each resident gets, shared across all shifts.
RN 0.73 · LPN 1.42 · Nurse aide 2.93. What the home's payroll records show.
RN 0.74 · LPN 0.92 · Nurse aide 2.50. What CMS predicts a home with these residents' needs would staff.
RN 0.68 · LPN 1.33 · Nurse aide 2.73. The reported hours rescaled so homes with sicker or healthier residents can be compared fairly.
Compared with CA and the nation
This home State average National average
- Total nurse hours (hrs/resident/day, higher is better)
- 5.08
✓ Better than the state average. State 4.54 · National 3.90
- Registered nurse (RN) hours (hrs/resident/day, higher is better)
- 0.73
✓ Better than the state average. State 0.68 · National 0.69
- Licensed nurse hours (RN + LPN) (hrs/resident/day, higher is better)
- 2.15
✓ Better than the state average. State 1.88 · National 1.55
- Nurse aide hours (hrs/resident/day, higher is better)
- 2.93
✓ Better than the state average. State 2.66 · National 2.35
- Weekend total nurse hours (hrs/resident/day, higher is better)
- 4.34
✓ Better than the state average. State 4.10 · National 3.43
- Weekend RN hours (hrs/resident/day, higher is better)
- 0.54
✓ Better than the state average. State 0.52 · National 0.48
- Physical therapist hours (hrs/resident/day, higher is better)
- 0.12
✓ Better than the state average. State 0.10 · National 0.07
- Nursing staff turnover (%, lower is better)
- 30.4%
✓ Better than the state average. State 36.6% · National 45.3%
- RN turnover (%, lower is better)
- 37.5%
≈ About the state average. State 37.8% · National 42.5%
- Administrators who left (people, lower is better)
- 1
✗ Worse than the state average. State 0 · National 1
- Nursing case-mix index (index)
- 1.50
State 1.51 · National 1.41
Turnover is the share of nursing staff who left over the year. The case-mix index shows how much care residents need: about 1.0 is typical, higher means more dependent residents.
Sources: Nursing Home Provider Information [1] ; Nursing Home State & National Averages [9] ; Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users' Guide [11]
Inspections
State inspectors visit each home about once a year and investigate complaints. Every problem they cite is a deficiency, lettered A to L by how serious and how widespread it was.
Health inspection score
65.0 points — in CA that earns (Above average).
Lower is better. The score adds up points for every citation (more for serious, widespread problems) and for revisits needed to confirm fixes, then weights recent inspections most. [11]
Score needed for each star in CA [10]
- 5 ★
- 0.000-33.000
- 4 ★ (this home)
- 33.001-66.000
- 3 ★
- 66.001-96.000
- 2 ★
- 96.001-146.000
- 1 ★
- >146.000
| Period | Inspection | Citations (complaint) | Citation points | Revisits | Revisit points | Total |
|---|---|---|---|---|---|---|
| Most recent cycle | Nov 26, 2025 | 17 (1) | 56 | 1 | 0 | 56 |
| Prior cycles (2 and 3) | Oct 24, 2024 | 25 (8) | 92 | 1 | 0 | 92 |
Health citations per inspection
Nov 26, 2025
Oct 24, 2024
Feb 10, 2023
State average for that cycle. Fewer is better.
Fire-safety citations per inspection
Nov 26, 2025
Oct 24, 2024
Feb 10, 2023
State average for that cycle. Fewer is better.
What the latest health inspection cited
- Resident Rights 4
- Infection Control 4
- Quality of Life and Care 3
- Resident Assessment and Care Planning 2
- Pharmacy Service 2
- Freedom from Abuse and Neglect and Exploitation 1
- Nutrition and Dietary 1
What the latest fire-safety inspection cited
- Construction 1
- Smoke 1
How serious were the citations?
Each health citation gets a letter. The number in each cell is how many of this home's citations got that letter; the points show what each letter adds to the health inspection score. Citations where care was substandard score higher than shown. [11]
| Isolated (a few residents) | Pattern (some residents) | Widespread (many residents) | |
|---|---|---|---|
| Immediate jeopardy to resident health or safety | J · 50 pts 0 | K · 100 pts 0 | L · 150 pts 0 |
| Actual harm, not immediate jeopardy | G · 20 pts 0 | H · 35 pts 0 | I · 45 pts 0 |
| No actual harm, potential for more than minimal harm | D · 4 pts 45 | E · 8 pts 4 | F · 16 pts 0 |
| No actual harm, potential for minimal harm only | A · 0 pts 0 | B · 0 pts 7 | C · 0 pts 0 |
Darker cells mean more citations. Counts cover every health citation CMS lists for this home.
All health citations (56) [2]
Inspection on Jun 2, 2026 · 1 citation
-
B
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 · Deficient, Provider has date of correction (Jun 17, 2026) · From a complaint
Inspection on Nov 26, 2025 · 16 citations
-
D
Reasonably accommodate the needs and preferences of each resident.
F0558 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Dec 18, 2025)
-
D
Allow residents to self-administer drugs if determined clinically appropriate.
F0554 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Dec 18, 2025)
-
B
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 · Deficient, Provider has date of correction (Dec 18, 2025)
-
D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
F0887 · Infection Control Deficiencies · Deficient, Provider has date of correction (Dec 18, 2025)
-
D
Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · Deficient, Provider has date of correction (Dec 18, 2025)
-
B
The resident has the right to receive notices in a format and a language he or she understands.
F0574 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Dec 18, 2025)
-
D
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 · Deficient, Provider has date of correction (Dec 18, 2025)
-
B
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
F0628 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Dec 18, 2025)
-
E
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 · Deficient, Provider has date of correction (Dec 18, 2025)
-
D
Ensure medication error rates are not 5 percent or greater.
F0759 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Dec 18, 2025)
-
D
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.
F0761 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Dec 18, 2025)
-
D
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 · Deficient, Provider has date of correction (Dec 18, 2025)
-
D
Implement a program that monitors antibiotic use.
F0881 · Infection Control Deficiencies · Deficient, Provider has date of correction (Dec 18, 2025)
-
D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F0883 · Infection Control Deficiencies · Deficient, Provider has date of correction (Dec 18, 2025)
-
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Dec 18, 2025)
-
D
Provide safe and appropriate respiratory care for a resident when needed.
F0695 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Dec 18, 2025)
Inspection on Sep 26, 2025 · 1 citation
-
D
Provide enough food/fluids to maintain a resident's health.
F0692 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Oct 26, 2025) · From a complaint
Inspection on Dec 26, 2024 · 1 citation
-
B
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 · Deficient, Provider has date of correction (Jan 13, 2025) · From a complaint
Inspection on Dec 6, 2024 · 2 citations
-
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Dec 29, 2024) · From a complaint
-
D
Respond appropriately to all alleged violations.
F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction (Dec 29, 2024) · From a complaint
Inspection on Oct 24, 2024 · 21 citations
-
D
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 · Deficient, Provider has date of correction (Nov 17, 2024)
-
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Nov 17, 2024)
-
D
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.
F0849 · Administration Deficiencies · Deficient, Provider has date of correction (Nov 17, 2024)
-
D
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.
F0761 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Nov 17, 2024)
-
D
Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · Deficient, Provider has date of correction (Nov 17, 2024)
-
D
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.
F0758 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Nov 17, 2024)
-
B
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.
F0803 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Nov 17, 2024) · From a complaint
-
D
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
F0813 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Nov 17, 2024)
-
D
Provide enough food/fluids to maintain a resident's health.
F0692 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Nov 17, 2024)
-
D
Allow residents to self-administer drugs if determined clinically appropriate.
F0554 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Nov 17, 2024)
-
D
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
F0801 · Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction (Nov 17, 2024)
-
D
Implement a program that monitors antibiotic use.
F0881 · Infection Control Deficiencies · Deficient, Provider has date of correction (Nov 17, 2024) · From a complaint
-
B
Provide safe and appropriate respiratory care for a resident when needed.
F0695 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Nov 17, 2024) · From a complaint
-
E
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 · Deficient, Provider has date of correction (Nov 17, 2024)
-
D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F0757 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Nov 17, 2024)
-
D
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 · Deficient, Provider has date of correction (Nov 17, 2024)
-
D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F0883 · Infection Control Deficiencies · Deficient, Provider has date of correction (Nov 17, 2024)
-
D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F0867 · Administration Deficiencies · Deficient, Provider has date of correction (Nov 17, 2024)
-
D
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 · Deficient, Provider has date of correction (Nov 17, 2024) · From a complaint
-
D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
F0582 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Nov 17, 2024)
-
D
Keep all essential equipment working safely.
F0908 · Environmental Deficiencies · Deficient, Provider has date of correction (Nov 17, 2024)
Inspection on Feb 10, 2023 · 14 citations
-
D
Provide or get specialized rehabilitative services as required for a resident.
F0825 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Mar 12, 2023)
-
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Mar 12, 2023)
-
D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F0623 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Mar 12, 2023)
-
D
Provide activities to meet all resident's needs.
F0679 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Mar 12, 2023)
-
D
Assist a resident in gaining access to vision and hearing services.
F0685 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Mar 12, 2023)
-
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Mar 12, 2023)
-
D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
F0553 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Mar 12, 2023)
-
D
Allow residents to self-administer drugs if determined clinically appropriate.
F0554 · Resident Rights Deficiencies · Deficient, Provider has date of correction (Mar 12, 2023)
-
D
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.
F0758 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Mar 12, 2023)
-
D
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.
F0761 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Mar 12, 2023)
-
E
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 · Deficient, Provider has date of correction (Mar 12, 2023)
-
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · Deficient, Provider has date of correction (Mar 12, 2023)
-
D
Provide safe and appropriate respiratory care for a resident when needed.
F0695 · Quality of Life and Care Deficiencies · Deficient, Provider has date of correction (Mar 12, 2023)
-
E
Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · Deficient, Provider has date of correction (Mar 12, 2023)
All fire-safety citations (19) [3]
Inspection on Nov 26, 2025 · 2 citations
-
C
Inspect, test, and maintain automatic sprinkler systems.
K0353 · Smoke Deficiencies · Deficient, Provider has date of correction (Dec 8, 2025)
-
D
Use approved construction type or materials.
K0161 · Construction Deficiencies · Deficient, Provider has date of correction (Dec 8, 2025)
Inspection on Oct 24, 2024 · 4 citations
-
D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K0761 · Miscellaneous Deficiencies · Deficient, Provider has date of correction (Nov 11, 2024)
-
D
Ensure proper usage of power strips and extension cords.
K0920 · Gas, Vacuum, and Electrical Systems Deficiencies · Deficient, Provider has date of correction (Nov 11, 2024)
-
C
Have approved installation, maintenance and testing program for fire alarm systems.
K0345 · Smoke Deficiencies · Deficient, Provider has date of correction (Nov 11, 2024)
-
E
Inspect, test, and maintain automatic sprinkler systems.
K0353 · Smoke Deficiencies · Deficient, Provider has date of correction (Nov 11, 2024)
Inspection on Feb 10, 2023 · 13 citations
-
D
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
K0926 · Gas, Vacuum, and Electrical Systems Deficiencies · Deficient, Provider has date of correction (Mar 6, 2023)
-
D
Have approved installation, maintenance and testing program for fire alarm systems.
K0345 · Smoke Deficiencies · Deficient, Provider has date of correction (Mar 6, 2023)
-
F
Conduct risk assessment and an All-Hazards approach.
E0006 · Emergency Preparedness Deficiencies · Deficient, Provider has date of correction (Mar 6, 2023)
-
D
Have generator or other power source capable of supplying service within 10 seconds.
K0918 · Gas, Vacuum, and Electrical Systems Deficiencies · Deficient, Provider has date of correction (Mar 6, 2023)
-
D
Provide properly sized and located linen or trash receptacles.
K0754 · Miscellaneous Deficiencies · Deficient, Provider has date of correction (Mar 6, 2023)
-
C
Provide primary/alternate means for communication.
E0032 · Emergency Preparedness Deficiencies · Deficient, Provider has date of correction (Mar 6, 2023)
-
C
Develop and maintain an Emergency Preparedness Program (EP).
E0004 · Emergency Preparedness Deficiencies · Deficient, Provider has date of correction (Mar 6, 2023)
-
C
Implement emergency and standby power systems.
E0041 · Emergency Preparedness Deficiencies · Deficient, Provider has date of correction (Mar 6, 2023)
-
C
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K0346 · Smoke Deficiencies · Deficient, Provider has date of correction (Mar 6, 2023)
-
C
Address subsistence needs for staff and patients.
E0015 · Emergency Preparedness Deficiencies · Deficient, Provider has date of correction (Mar 6, 2023)
-
D
Have simulated fire drills held at unexpected times.
K0712 · Miscellaneous Deficiencies · Deficient, Provider has date of correction (Mar 6, 2023)
-
E
Install corridor and hallway doors that block smoke.
K0363 · Smoke Deficiencies · Deficient, Provider has date of correction (Mar 6, 2023)
-
D
Provide family notifications of emergency plan.
E0035 · Emergency Preparedness Deficiencies · Deficient, Provider has date of correction (Mar 6, 2023)
Sources: Nursing Home Provider Information [1] ; Nursing Home Survey Summary [4] ; Nursing Home Health Deficiencies [2] ; Nursing Home Fire Safety Deficiencies [3] ; Nursing Home Health Inspection Cut Points [10] ; Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users' Guide [11]
Fines & penalties
CMS can fine a home or stop Medicare and Medicaid payments for new admissions when problems are serious or keep recurring. Most homes have none.
- Fines
- 0 State avg 0.8 · National 0.9
- Total fined
- $0 State avg 23,366 · National 30,351
- Payment denials
- 0 Periods with no Medicare/Medicaid payment for new admissions
Sources: Nursing Home Provider Information [1] ; Nursing Home Penalties [5] ; Nursing Home State & National Averages [9]
Resident quality measures
These measure what actually happens to residents, as a percentage from 0 to 100 (or events per 1,000 resident days). For almost all of them a lower number is better; the vaccination measures are the exception and are marked. A star means the measure counts toward the quality star rating.
This home State average National average
Long-stay residents (14) [7]
Residents who live in the home. From their regular health assessments (the Minimum Data Set), averaged over four quarters. Period: 2025Q3-2026Q2.
- Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Higher is better
- 100.0
≈ About the state average. State 98.7 · National 93.7
- Percentage of long-stay residents experiencing one or more falls with major injury ★ Lower is better
- 0.0
✓ Better than the state average. State 1.6 · National 3.2
- Percentage of long-stay residents who have depressive symptoms Lower is better
- 0.0
✓ Better than the state average. State 7.6 · National 13.5
- Percentage of long-stay residents who lose too much weight Lower is better
- 0.0
✓ Better than the state average. State 4.1 · National 5.1
- Percentage of long-stay residents who received an antianxiety or hypnotic medication Lower is better
- 9.1
✓ Better than the state average. State 13.7 · National 19.5
- Percentage of long-stay residents who received an antipsychotic medication ★ Lower is better
- 10.4
✓ Better than the state average. State 12.3 · National 15.4
- Percentage of long-stay residents who were physically restrained Lower is better
- 0.0
✓ Better than the state average. State 0.3 · National 0.1
- Percentage of long-stay residents whose ability to walk independently worsened ★ Lower is better
- 14.3
✗ Worse than the state average. State 8.9 · National 12.7
- Percentage of long-stay residents whose need for help with daily activities has increased ★ Lower is better
- 11.1
✗ Worse than the state average. State 10.2 · National 13.5
- Percentage of long-stay residents with a catheter inserted and left in their bladder ★ Lower is better
- 0.0
✓ Better than the state average. State 0.7 · National 0.7
- Percentage of long-stay residents with a urinary tract infection ★ Lower is better
- 0.0
✓ Better than the state average. State 1.2 · National 1.5
- Percentage of long-stay residents with new or worsened bowel or bladder incontinence Lower is better
- 21.5
✗ Worse than the state average. State 9.8 · National 18.3
- Percentage of long-stay residents with pressure ulcers ★ Lower is better
- 4.7
✗ Worse than the state average. State 4.3 · National 4.5
Short-stay residents (3) [7]
Residents staying for rehab or recovery. From their health assessments, averaged over four quarters. Period: 2025Q3-2026Q2.
- Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Higher is better
- 99.7
✓ Better than the state average. State 94.6 · National 82.3
- Percentage of short-stay residents who newly received an antipsychotic medication ★ Lower is better
- 0.6
✓ Better than the state average. State 1.3 · National 1.5
- Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine Higher is better
- 100.0
✓ Better than the state average. State 93.1 · National 80.1
Long-stay residents: hospital use (2) [8]
Hospital stays and emergency visits found in Medicare claims, adjusted for how sick residents were. Period: 20250401-20260331.
Short-stay residents: hospital use (2) [8]
Rehospitalizations and emergency visits after admission, found in Medicare claims and adjusted for how sick residents were. Period: 20250401-20260331.
- Percentage of short-stay residents who had an outpatient emergency department visit ★ Lower is better · Expected for these residents: 10.2
- 9.3
✓ Better than the state average. State 11.1 · National 11.8
- Percentage of short-stay residents who were rehospitalized after a nursing home admission ★ Lower is better · Expected for these residents: 20.4
- 19.9
✓ Better than the state average. State 22.6 · National 23.4
Sources: Nursing Home MDS Quality Measures [7] ; Nursing Home Medicare Claims Quality Measures [8] ; Nursing Home State & National Averages [9] ; Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users' Guide [11]
Ownership & operator
Who owns and runs a home can matter: for-profit, non-profit and chain-owned homes tend to differ on staffing and inspection results.
- Ownership type
- For profit - Partnership
- Legal business name
- CASA PACIFICA
- Certified for
- Medicare and Medicaid
- Certified beds
- 52
- Residents per day (average)
- 39.8
- In Medicare/Medicaid since
- Oct 26, 1989
- Resident and family council
- Resident
- Sprinklers in all required areas
- Yes
- County
- Orange
- Located in a hospital
- No
Owners, officers and managers (31) [6]
Individual Is An Owner, Partner Or Trustee Of Any Adp Of The Snf
- CASINO, MARIANNE (individual, NOT APPLICABLE, since 05/29/2026)
- ROSKAMP, RUTH (individual, NOT APPLICABLE, since 05/29/2026)
5% Or Greater Indirect Ownership Interest
- CDR INVESTMENT GROUP, LLC (organization, since 12/31/2025)
- DEBBAN, SUSAN (individual, since 10/26/1989)
- FRANCESE, CELIA (individual, since 03/17/2026)
- FREEDOM GROUP-CALIFORNIA LLC (organization, since 10/26/1989)
- KUBICKA, CHARLES (individual, since 10/26/1989)
- MANGIARACINA, EMILY (individual, since 01/01/2022)
- MURPHY, TIMOTHY (individual, since 01/05/2020)
- R.J. WADE LIMITED PARTNERSHIP, LLP (organization, since 10/26/1989)
- ROSKAMP, CHERYL (individual, since 01/01/2026)
- ROSKAMP, DENISE (individual, since 01/01/2026)
- ROSKAMP, RANDALL (individual, since 01/01/2026)
- ROSKAMP, ROBERT (individual, since 10/26/1989)
- ROSKAMP, STEVEN (individual, since 01/01/2022)
- STRINGER FAMILY PARTNERSHIP (organization, since 06/01/2009)
- STRINGER, THOMAS (individual, since 10/26/1989)
- WADE, RICHARD (individual, since 10/26/1989)
Adp Of The Snf
- FREEDOM MANAGEMENT CO LLC (organization, NOT APPLICABLE, since 05/29/2026)
- MANGIARACINA, EMILY (individual, NOT APPLICABLE, since 06/01/2020)
- ROSKAMP, CHERYL (individual, NOT APPLICABLE, since 12/09/2020)
- STEWART, SELINA (individual, NOT APPLICABLE, since 03/27/2026)
- SUCKIEL, JENNIFER (individual, NOT APPLICABLE, since 06/15/2019)
- TABATABAI, ALI (individual, NOT APPLICABLE, since 01/01/2023)
General Partnership Interest
- FREEDOM PROPERTIES WEST LLC (organization, NOT APPLICABLE, since 01/01/1986)
- HEMET RETIREMENT PROPERTIES WEST, LLC (organization, NOT APPLICABLE, since 01/01/2025)
- QUANTUM BASICS II, LLC (organization, NOT APPLICABLE, since 01/05/2020)
- TARAYAN INC (organization, NOT APPLICABLE, since 10/26/1989)
Operational/Managerial Control
- ROSKAMP, CHERYL (individual, NOT APPLICABLE, since 12/09/2020)
- STEWART, SELINA (individual, NOT APPLICABLE, since 03/27/2026)
- SUCKIEL, JENNIFER (individual, NOT APPLICABLE, since 06/15/2019)
Sources: Nursing Home Provider Information [1] ; Nursing Home Ownership [6]
Sources
All figures on this page come from the U.S. government's published nursing home data, as of October 1, 2026. We reproduce them without change except for rounding and layout; ratings, scores and flags are CMS's, not ours. Averages and comparisons use the state and national figures CMS publishes in the same release.
- 1. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Provider Information. Star ratings, staffing, turnover, inspection scores, fines, chain and flag data. https://data.cms.gov/provider-data/dataset/4pq5-n9py
- 2. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Health Deficiencies. Each health deficiency cited, with scope and severity. https://data.cms.gov/provider-data/dataset/r5ix-sfxw
- 3. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Fire Safety Deficiencies. Each fire-safety deficiency cited. https://data.cms.gov/provider-data/dataset/ifjz-ge4w
- 4. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Survey Summary. Deficiency totals by inspection cycle and category. https://data.cms.gov/provider-data/dataset/tbry-pc2d
- 5. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Penalties. Fines and payment denials. https://data.cms.gov/provider-data/dataset/g6vv-u9sr
- 6. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Ownership. Owners, officers, directors and managers. https://data.cms.gov/provider-data/dataset/y2hd-n93e
- 7. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home MDS Quality Measures. Quarterly quality measure scores from resident assessments. https://data.cms.gov/provider-data/dataset/djen-97ju
- 8. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Medicare Claims Quality Measures. Risk-adjusted quality measures from Medicare claims. https://data.cms.gov/provider-data/dataset/ijh5-nb2v
- 9. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home State & National Averages. State and national averages used for comparison. https://data.cms.gov/provider-data/dataset/xcdc-v8bm
- 10. Centers for Medicare & Medicaid Services, Provider Data Catalog. Nursing Home Health Inspection Cut Points. Score ranges that earn each health inspection star in a state. https://data.cms.gov/provider-data/dataset/hicp-9999
- 11. Centers for Medicare & Medicaid Services. Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users' Guide. How the star ratings, scope and severity points, and abuse and Special Focus flags are defined. https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/downloads/usersguide.pdf
- 12. Centers for Medicare & Medicaid Services. Medicare Care Compare. CMS's own consumer site, with the latest figures. https://www.medicare.gov/care-compare/
Attendant Homes is not affiliated with or endorsed by CMS. The data describes past inspections and reported figures and can be out of date or contain errors; it is not a recommendation. Confirm current information with the facility and on Medicare Care Compare [12] .
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