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Nursing HomeMedicaid Investigative

Cedar Pine Post Acute

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

1640 N. Fair Oaks Avenue, North Central · Pasadena, CA 9110399 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
2.9/5

based on 33 Google reviews

5
4
3
2
1
Cedar Pine Post Acute Nursing Home in Pasadena, CA — Street View
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3/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (2/5 stars)
  • Above-median deficiencies (26 vs median 13.0)

Below average in CA · Below recommended RN staffing · Above recommended total nurse staffing · Below chain average · $38,213 in fines

Source: Medicare data

What this means for your family

This facility presents significant risks regarding patient safety, specifically concerning medication errors and the theft of personal belongings. While some recent feedback is positive, the recurring pattern of severe neglect and mismanagement is too frequent to ignore; families should conduct an unannounced visit and verify nursing competency before admission.

Google Reviews

Google Reviews

33 reviews on Google
Families should exercise extreme caution when considering Cedar Pine Post Acute due to severe allegations of medical neglect, theft of personal property, and medication mismanagement. While a single recent review offers high praise for the warm environment, the historical pattern of reviews highlights critical failures in patient safety, staff competence, and administrative oversight.

Quality Themes

FoodN/AStaff1.0Clean2.0ActivitiesN/AMeds1.0Memory1.0Comms2.0ValueN/A

Strengths

  • Warm and welcoming environment (mentioned in one recent review)
  • Renovated outdoor spaces like the yard and patio
  • Availability of medical and dental services

Concerns

  • Medical neglect and improper medication administration (mentioned by 3 reviewers)
  • Theft of personal property and money (mentioned by 2 reviewers)
  • Poor facility cleanliness and maintenance (mentioned by 2 reviewers)
  • Incompetent or untrained nursing staff (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'17(8)'19(2)'21(3)'24(2)'26(4)

Distribution · 36 analyzed

5
11
4
5
3
4
2
1
1
15

How They Respond to Reviews

17%response rate
Generic

The owner relies heavily on a standardized template for patient/family complaints, using nearly identical language to request follow-up calls. For employee-related complaints, the response shifts to a different, equally canned professional dismissal.

Questions for Your Tour

  • 1It is wonderful to see the renovated patio and yard; what kind of outdoor activities or social gatherings do you host for residents in these spaces?
  • 2How does your nursing team ensure that medication is administered accurately and on schedule every day?
  • 3What specific protocols do you have in place to ensure the facility remains clean, sanitized, and well-maintained for the residents?
  • 4Could you tell me more about the specialized care and daily programming available for residents in your memory care unit?
  • 5How do you handle communication between the nursing staff and family members regarding changes in a resident's health or daily needs?
  • 6In the event of a medical emergency after hours, what is the immediate process for coordinating care and notifying the family?

Personalized based on this facility's data


Key Review Excerpts

The environment is terrible my grandma was very sick and the nurse didn’t check unless someone was there on her and accusing her of faking her sickness.

Grandchild of resident · 2026☆☆☆☆

They over medicate, there was blood all over the front of one of my mom's shirt, they stole $20 from her purse and came back with half the clothes she left with, and she came back in worse condition than when she left and died 2 weeks after being there!!!

Daughter of deceased resident · 2024☆☆☆☆

This place lost my Father's book collection, has done nothing about the repeated thieft of his personal property, the neglect of my dad's health led to the inability of his leg, and now they are taking control of his finances...

Son of deceased resident · 2020☆☆☆☆
Source: 33 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.46hrs
62%
Registered nurses for medical care
Total Nursing
4.22hrs
OK
All nurses + aides combined
Staff Turnover
36%
Lower is better (< 30% = good)
RN Turnover
38%
Lower is better (< 30% = good)

RN hours are below the national benchmark. RNs handle complex medical needs and medication, so ask about coverage during your visit.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
5/ 5
Better Than Avg

11

measures

Worse Than Avg

5

measures

Mixed Results

1

measures

Long-Stay Residents
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility2.6%
Better than Avg
Here
2.6%
US
19.4%
CA
10.7%
Los angeles
9.7%
😔

Residents with depression symptoms

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
12.1%
CA
7.0%
Los angeles
8.7%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on antipsychotic medication

↓ Lower is better
This Facility6.1%
Better than Avg
Here
6.1%
US
15.5%
CA
11.7%
Los angeles
11.4%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility6.0%
Better than Avg
Here
6.0%
US
15.3%
CA
10.5%
Los angeles
9.5%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility11.6%
Mixed vs Avgs
Here
11.6%
US
19.5%
CA
13.7%
Los angeles
10.8%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
93.4%
CA
98.6%
Los angeles
99.1%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
79.8%
CA
93.2%
Los angeles
92.5%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
81.8%
CA
94.2%
Los angeles
94.5%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility3.7%
Worse than Avg
Here
3.7%
US
1.6%
CA
1.5%
Los angeles
1.5%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

26deficiencies
1penalties
Well above state avg (15.4)
31 complaint-triggered
$38,213 in fines

This facility shows concerning patterns with frequent family complaints prompting federal investigations. The most recurring problems involve accident prevention and safety hazards, medication management, and care planning. While all deficiencies show correction dates, the persistent nature of safety issues across multiple complaint-driven surveys suggests ongoing quality concerns that families should carefully evaluate during visits.

Apr 23, 2026Complaint
2
0755Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0694Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Apr 14, 2026Complaint
2
0842Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Dec 23, 2025Complaint
1
0755Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Dec 19, 2025Complaint
1
0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Dec 9, 2025Complaint
1
0605Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Nov 26, 2025Complaint
1
0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Federal Penalties

Fine

Apr 19, 2025

$9,113

Ownership & Operations

Who Operates This Facility

Owner / Operator

Cedar Pine Post Acute

Organization Type

for profit

Chain Affiliation

Chain Name

Eva Care Group

Chain Size

9 facilities nationwide

Chain avg rating: 3.3/5 · Rank 7 of 8

Ownership & Management

Owners

Chen, Jenq

Owner

Chen, Tze-Yun

Owner

Key personnel

Padama, JohnOfficer / DirectorAgulto, IsidraManagerSong, JamesManagerAgulto, IsidraAdp of the SnfChen, JenqAdp of the Snf
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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