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Data / Nursing homes / California / Monrovia Gardens Healthcare Center

Monrovia Gardens Healthcare Center, Monrovia, CA: 1 star rating, no fines

Monrovia Gardens Healthcare Center in Monrovia, CA is owned by Ag Facilities Operations, LLC, is rated 1 of 5 stars by Medicare, and had no fines in the three years to October 1, 2026. CMS lists 104 health citations from inspections in that time, the latest survey on July 15, 2026, and 1 of them found actual harm or immediate jeopardy.

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Address
615 W. Duarte Rd., Monrovia, CA 91016
Overall rating
1 of 5 stars
Health inspection rating
1 of 5
Staffing rating
3 of 5
Quality measure rating
2 of 5
Certified beds
96
Residents per day
82 on average
Ownership type
For profit, limited liability company
Legal business name
Ag Monrovia, LLC
Chain
Cambridge Healthcare Services, 32 facilities
Fines
$0 across 0 fines, three years to October 1, 2026
Payment denials
0
Health citations
104, of which 1 with actual harm or immediate jeopardy
Latest survey
July 15, 2026
CMS Certification Number
055367
On Care Compare
Medicare Care Compare

Recent health citations

Citations from health inspections, newest first. These are the latest 100 of 104.

Survey dateTagWhat CMS citedScope and severityStatusCorrected onSource
July 15, 2026F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 17, 2026data.cms.gov
July 8, 2026F919Make sure that a working call system is available in each resident's bathroom and bathing area.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 10, 2026data.cms.gov
July 8, 2026F803Ensure 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.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 10, 2026data.cms.gov
July 8, 2026F677Provide care and assistance to perform activities of daily living for any resident who is unable.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 10, 2026data.cms.gov
June 23, 2026F757Ensure each resident’s drug regimen must be free from unnecessary drugs.E: pattern, no actual harm, potential for more than minimal harmCorrectedJune 25, 2026data.cms.gov
June 23, 2026F552Ensure that residents are fully informed and understand their health status, care and treatments.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 13, 2026data.cms.gov
June 4, 2026F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.D: isolated, no actual harm, potential for more than minimal harmCorrectedJune 5, 2026data.cms.gov
March 3, 2026F698Provide safe, appropriate dialysis care/services for a resident who requires such services.D: isolated, no actual harm, potential for more than minimal harmCorrectedMarch 23, 2026data.cms.gov
March 3, 2026F687Provide appropriate foot care.D: isolated, no actual harm, potential for more than minimal harmCorrectedMarch 23, 2026data.cms.gov
March 3, 2026F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.E: pattern, no actual harm, potential for more than minimal harmCorrectedMarch 23, 2026data.cms.gov
December 19, 2025F881Implement a program that monitors antibiotic use.D: isolated, no actual harm, potential for more than minimal harmCorrectedDecember 29, 2025data.cms.gov
December 19, 2025F880Provide and implement an infection prevention and control program.D: isolated, no actual harm, potential for more than minimal harmCorrectedDecember 29, 2025data.cms.gov
December 19, 2025F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E: pattern, no actual harm, potential for more than minimal harmCorrectedDecember 29, 2025data.cms.gov
December 19, 2025F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.E: pattern, no actual harm, potential for more than minimal harmCorrectedDecember 29, 2025data.cms.gov
December 19, 2025F695Provide safe and appropriate respiratory care for a resident when needed.D: isolated, no actual harm, potential for more than minimal harmCorrectedDecember 29, 2025data.cms.gov
December 19, 2025F693Ensure 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.D: isolated, no actual harm, potential for more than minimal harmCorrectedDecember 29, 2025data.cms.gov
December 19, 2025F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D: isolated, no actual harm, potential for more than minimal harmCorrectedDecember 29, 2025data.cms.gov
December 19, 2025F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.D: isolated, no actual harm, potential for more than minimal harmCorrectedDecember 29, 2025data.cms.gov
December 19, 2025F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.E: pattern, no actual harm, potential for more than minimal harmCorrectedDecember 29, 2025data.cms.gov
December 19, 2025F679Provide activities to meet all resident's needs.D: isolated, no actual harm, potential for more than minimal harmCorrectedDecember 29, 2025data.cms.gov
December 19, 2025F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D: isolated, no actual harm, potential for more than minimal harmCorrectedDecember 29, 2025data.cms.gov
December 19, 2025F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D: isolated, no actual harm, potential for more than minimal harmCorrectedDecember 29, 2025data.cms.gov
December 19, 2025F606Not hire anyone with a finding of abuse, neglect, exploitation, or theft.D: isolated, no actual harm, potential for more than minimal harmCorrectedDecember 29, 2025data.cms.gov
December 19, 2025F578Honor 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.E: pattern, no actual harm, potential for more than minimal harmCorrectedDecember 29, 2025data.cms.gov
December 19, 2025F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.D: isolated, no actual harm, potential for more than minimal harmCorrectedDecember 30, 2025data.cms.gov
October 31, 2025F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 18, 2025data.cms.gov
September 17, 2025F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 23, 2025data.cms.gov
September 3, 2025F808Ensure 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.D: isolated, no actual harm, potential for more than minimal harmCorrectedSeptember 23, 2025data.cms.gov
September 3, 2025F677Provide care and assistance to perform activities of daily living for any resident who is unable.E: pattern, no actual harm, potential for more than minimal harmCorrectedSeptember 24, 2025data.cms.gov
September 3, 2025F558Reasonably accommodate the needs and preferences of each resident.D: isolated, no actual harm, potential for more than minimal harmCorrectedSeptember 23, 2025data.cms.gov
August 27, 2025F908Keep all essential equipment working safely.E: pattern, no actual harm, potential for more than minimal harmCorrectedSeptember 15, 2025data.cms.gov
August 5, 2025F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.E: pattern, no actual harm, potential for more than minimal harmCorrectedAugust 21, 2025data.cms.gov
August 5, 2025F677Provide care and assistance to perform activities of daily living for any resident who is unable.E: pattern, no actual harm, potential for more than minimal harmCorrectedAugust 30, 2025data.cms.gov
August 5, 2025F558Reasonably accommodate the needs and preferences of each resident.E: pattern, no actual harm, potential for more than minimal harmCorrectedAugust 27, 2025data.cms.gov
July 9, 2025F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 11, 2025data.cms.gov
July 9, 2025F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.D: isolated, no actual harm, potential for more than minimal harmCorrectedJune 27, 2025data.cms.gov
July 9, 2025F558Reasonably accommodate the needs and preferences of each resident.D: isolated, no actual harm, potential for more than minimal harmCorrectedJuly 11, 2025data.cms.gov
May 13, 2025F677Provide care and assistance to perform activities of daily living for any resident who is unable.D: isolated, no actual harm, potential for more than minimal harmCorrectedMay 14, 2025data.cms.gov
May 13, 2025F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.D: isolated, no actual harm, potential for more than minimal harmCorrectedMay 14, 2025data.cms.gov
May 13, 2025F558Reasonably accommodate the needs and preferences of each resident.D: isolated, no actual harm, potential for more than minimal harmCorrectedMay 14, 2025data.cms.gov
April 24, 2025F880Provide and implement an infection prevention and control program.E: pattern, no actual harm, potential for more than minimal harmCorrectedApril 25, 2025data.cms.gov
April 24, 2025F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D: isolated, no actual harm, potential for more than minimal harmCorrectedMay 13, 2025data.cms.gov
March 27, 2025F807Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.D: isolated, no actual harm, potential for more than minimal harmCorrectedMarch 28, 2025data.cms.gov
March 27, 2025F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.D: isolated, no actual harm, potential for more than minimal harmCorrectedMarch 28, 2025data.cms.gov
March 27, 2025F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.E: pattern, no actual harm, potential for more than minimal harmCorrectedApril 1, 2025data.cms.gov
March 27, 2025F697Provide safe, appropriate pain management for a resident who requires such services.D: isolated, no actual harm, potential for more than minimal harmCorrectedApril 1, 2025data.cms.gov
March 27, 2025F677Provide care and assistance to perform activities of daily living for any resident who is unable.D: isolated, no actual harm, potential for more than minimal harmCorrectedApril 1, 2025data.cms.gov
March 27, 2025F583Keep residents' personal and medical records private and confidential.D: isolated, no actual harm, potential for more than minimal harmCorrectedApril 1, 2025data.cms.gov
February 26, 2025F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.E: pattern, no actual harm, potential for more than minimal harmCorrectedMarch 20, 2025data.cms.gov
February 26, 2025F688Provide 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.E: pattern, no actual harm, potential for more than minimal harmCorrectedMarch 20, 2025data.cms.gov
February 26, 2025F584Honor 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.D: isolated, no actual harm, potential for more than minimal harmCorrectedMarch 21, 2025data.cms.gov
February 10, 2025F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D: isolated, no actual harm, potential for more than minimal harmCorrectedFebruary 12, 2025data.cms.gov
January 24, 2025F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.G: isolated, actual harmCorrectedFebruary 20, 2025data.cms.gov
January 24, 2025F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.D: isolated, no actual harm, potential for more than minimal harmCorrectedJanuary 29, 2025data.cms.gov
January 24, 2025F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.E: pattern, no actual harm, potential for more than minimal harmCorrectedJanuary 27, 2025data.cms.gov
January 24, 2025F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.D: isolated, no actual harm, potential for more than minimal harmCorrectedFebruary 20, 2025data.cms.gov
January 24, 2025F677Provide care and assistance to perform activities of daily living for any resident who is unable.E: pattern, no actual harm, potential for more than minimal harmCorrectedFebruary 12, 2025data.cms.gov
January 24, 2025F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D: isolated, no actual harm, potential for more than minimal harmCorrectedJanuary 29, 2025data.cms.gov
January 24, 2025F576Ensure residents have reasonable access to and privacy in their use of communication methods.D: isolated, no actual harm, potential for more than minimal harmCorrectedJanuary 29, 2025data.cms.gov
December 31, 2024F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.E: pattern, no actual harm, potential for more than minimal harmCorrectedJanuary 2, 2025data.cms.gov
December 24, 2024F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.D: isolated, no actual harm, potential for more than minimal harmCorrectedDecember 26, 2024data.cms.gov
December 24, 2024F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.D: isolated, no actual harm, potential for more than minimal harmCorrectedJanuary 14, 2025data.cms.gov
November 25, 2024F610Respond appropriately to all alleged violations.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 28, 2024data.cms.gov
October 31, 2024F919Make sure that a working call system is available in each resident's bathroom and bathing area.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 19, 2024data.cms.gov
October 31, 2024F880Provide and implement an infection prevention and control program.E: pattern, no actual harm, potential for more than minimal harmCorrectedNovember 15, 2024data.cms.gov
October 31, 2024F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E: pattern, no actual harm, potential for more than minimal harmCorrectedNovember 4, 2024data.cms.gov
October 31, 2024F803Ensure 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.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 1, 2024data.cms.gov
October 31, 2024F790Provide routine and 24-hour emergency dental care for each resident.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 19, 2024data.cms.gov
October 31, 2024F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.E: pattern, no actual harm, potential for more than minimal harmCorrectedNovember 5, 2024data.cms.gov
October 31, 2024F692Provide enough food/fluids to maintain a resident's health.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 15, 2024data.cms.gov
October 31, 2024F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.E: pattern, no actual harm, potential for more than minimal harmCorrectedNovember 20, 2024data.cms.gov
October 31, 2024F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.E: pattern, no actual harm, potential for more than minimal harmCorrectedNovember 20, 2024data.cms.gov
October 31, 2024F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.E: pattern, no actual harm, potential for more than minimal harmCorrectedNovember 20, 2024data.cms.gov
October 31, 2024F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 18, 2024data.cms.gov
October 31, 2024F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 24, 2024data.cms.gov
October 31, 2024F641Ensure each resident receives an accurate assessment.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 19, 2024data.cms.gov
October 31, 2024F625Notify 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.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 20, 2024data.cms.gov
October 31, 2024F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 18, 2024data.cms.gov
October 31, 2024F578Honor 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.E: pattern, no actual harm, potential for more than minimal harmCorrectedNovember 18, 2024data.cms.gov
October 31, 2024F558Reasonably accommodate the needs and preferences of each resident.E: pattern, no actual harm, potential for more than minimal harmCorrectedOctober 31, 2024data.cms.gov
October 31, 2024F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 18, 2024data.cms.gov
June 21, 2024F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.D: isolated, no actual harm, potential for more than minimal harmCorrectedJune 27, 2024data.cms.gov
May 29, 2024F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.D: isolated, no actual harm, potential for more than minimal harmCorrectedAugust 2, 2024data.cms.gov
May 9, 2024F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.E: pattern, no actual harm, potential for more than minimal harmCorrectedMay 10, 2024data.cms.gov
May 9, 2024F880Provide and implement an infection prevention and control program.D: isolated, no actual harm, potential for more than minimal harmCorrectedMay 9, 2024data.cms.gov
May 9, 2024F688Provide 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.D: isolated, no actual harm, potential for more than minimal harmCorrectedMay 15, 2024data.cms.gov
October 19, 2023F880Provide and implement an infection prevention and control program.E: pattern, no actual harm, potential for more than minimal harmCorrectedNovember 14, 2023data.cms.gov
October 19, 2023F837Establish 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.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 14, 2023data.cms.gov
October 19, 2023F825Provide or get specialized rehabilitative services as required for a resident.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 14, 2023data.cms.gov
October 19, 2023F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E: pattern, no actual harm, potential for more than minimal harmCorrectedNovember 14, 2023data.cms.gov
October 19, 2023F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 14, 2023data.cms.gov
October 19, 2023F770Provide timely, quality laboratory services/tests to meet the needs of residents.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 14, 2023data.cms.gov
October 19, 2023F761Ensure 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.E: pattern, no actual harm, potential for more than minimal harmCorrectedNovember 14, 2023data.cms.gov
October 19, 2023F759Ensure medication error rates are not 5 percent or greater.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 14, 2023data.cms.gov
October 19, 2023F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 14, 2023data.cms.gov
October 19, 2023F692Provide enough food/fluids to maintain a resident's health.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 14, 2023data.cms.gov
October 19, 2023F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 14, 2023data.cms.gov
October 19, 2023F685Assist a resident in gaining access to vision and hearing services.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 14, 2023data.cms.gov
October 19, 2023F658Ensure services provided by the nursing facility meet professional standards of quality.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 14, 2023data.cms.gov
October 19, 2023F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D: isolated, no actual harm, potential for more than minimal harmCorrectedNovember 14, 2023data.cms.gov

Full inspection reports on Medicare Care Compare

Owners and managers

Organizations CMS lists as owners or managers of this facility, as CMS names them. CMS also lists 24 individual or personal trusts (13 managers, 1 officers, directors or trustees, 10 other disclosable parties). Their names are not shown on this page.

OrganizationRoleShareSinceSource
Ag Facilities Operations, LLCDirect owner100%August 11, 2003data.cms.gov
Ira E Smedra Living TrustIndirect owner48%August 11, 2003data.cms.gov
Win Win Enterprises, LLCIndirect owner48%August 11, 2003data.cms.gov
Cambridge Healthcare Services LLCOperational or managerial controlNot listedOctober 1, 2013data.cms.gov
615 W. Duarte, LLCAdditional disclosable partyNot listedOctober 1, 2003data.cms.gov
Cambridge Healthcare Services LLCAdditional disclosable partyNot listedOctober 24, 2025data.cms.gov
Win Win Enterprises, LLCAdditional disclosable partyNot listedOctober 1, 2003data.cms.gov

Also on SpecStream

Updated November 7, 2026. Read from CMS Provider Data Catalog, nursing homes. Open data from the Centers for Medicare & Medicaid Services (US government work). Fines and citations are as CMS lists them on the date this page was read and can change after an appeal. The CMS files are joined on the CMS Certification Number. CMS gives owners no ID, so an owner page groups facilities by the owner name as CMS spells it. Names of individual owners and managers are not shown. This page uses CMS data and is not endorsed or certified by CMS. Free to reuse with credit to SpecStream under CC BY 4.0. Spot a wrong value? Write to [email protected] with the link to this page.