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Nursing HomeMedicaid Investigative

Gordon Lane Care Center

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

1821 E Chapman Ave, Fullerton, CA 9283199 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
4.2/5

based on 106 Google reviews

5
4
3
2
1
Gordon Lane Care Center Nursing Home in Fullerton, 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 (28 vs median 13.0)

Below average in CA · Critically understaffed (RN) · Above recommended total nurse staffing · Low staff turnover (stable workforce) · Below chain average · No penalties on record

Source: Medicare data

What this means for your family

This facility is an excellent choice for rehabilitation and post-surgery recovery due to its highly skilled therapy teams and clean environment. However, families should closely monitor medication administration and ensure all personal belongings are clearly labeled and inventoried, as multiple reviewers have reported issues with lost property and medication errors.

Google Reviews

Google Reviews

106 reviews on Google
Gordon Lane Care Center is widely praised by families for its compassionate, professional nursing staff and its effective rehabilitation programs for post-surgery recovery. While many reviewers highlight the clean environment and engaging activities, there are serious, recurring allegations regarding neglect, medication errors, and the loss of personal property.

Quality Themes

Tap a score for details
Food4.0Staff8.0Clean9.0Activities9.0Meds3.0MemoryN/AComms6.0ValueN/A

Strengths

  • Compassionate and attentive nursing staff
  • Effective physical and occupational therapy
  • Clean and well-maintained facility
  • Engaging resident activities and social programs

Concerns

  • Loss or mismanagement of personal belongings (mentioned by 2 reviewers)
  • Slow response times to call lights (mentioned by 3 reviewers)
  • Issues with hygiene and resident care (e.g., changing/bathing) (mentioned by 3 reviewers)
  • Inconsistent food quality (mentioned by 3 reviewers)

Rating Trends

Tap a year to see what changed

234'13(1)'16(1)'18(2)'20(1)'22(6)'24(10)'26(19)

Distribution · 101 analyzed

5
71
4
11
3
1
2
6
1
12

How They Respond to Reviews

100%response rate
Good

The owner provides mostly personalized responses that acknowledge specific family members or staff members mentioned in the reviews. While they use several recurring templates, they frequently tailor the greeting and content to reflect the reviewer's specific sentiment.

Questions for Your Tour

  • 1We've noticed how much the management team engages with the community online; how does that same level of communication translate to how you update families on a resident's daily care?
  • 2With the focus on physical and occupational therapy here, how do you work with the therapy team to help residents maintain their mobility and independence?
  • 3What specific steps are in place to ensure that medication administration is handled with high precision and that call lights are answered promptly during the night shifts?
  • 4How do you manage the tracking of personal belongings to ensure that items like clothing or small keepsakes stay safe and organized within the resident's room?
  • 5Can you tell us more about the daily social programs and how you ensure residents are actively engaged in the community activities?
  • 6In the event of a sudden change in a resident's medical condition or an emergency after hours, what is the specific protocol for notifying the family and coordinating care?

Personalized based on this facility's data


Key Review Excerpts

The care he received was excellent. The staff are warm, friendly and caring. The ratios were high, which surprised me as we expected to have slow response time, but the staff is quick.

Rehab patient's family · 2025★★★★★

My uncle had 2 heart attacks. When he arrived he could not move on his own. When he left months later he was able to walk out with a cane.

Long-term resident's family · 2025★★★★★

The physical therapy team Jen, Krista, Kristle... a... [was impressive]

Long-term resident's family · 2023★★★★★
Source: 106 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.34hrs
46%
Registered nurses for medical care
Total Nursing
4.16hrs
OK
All nurses + aides combined
Staff Turnover
29%
Lower is better (< 30% = good)
RN Turnover
17%
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
4/ 5
Better Than Avg

14

measures

Mixed Results

3

measures

Long-Stay Residents
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility9.2%
Better than Avg
Here
9.2%
US
19.4%
CA
10.7%
Orange
9.8%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility7.2%
Better than Avg
Here
7.2%
US
15.3%
CA
10.5%
Orange
9.6%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
93.4%
CA
98.6%
Orange
98.6%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility9.0%
Better than Avg
Here
9.0%
US
15.5%
CA
11.7%
Orange
9.1%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility13.9%
Mixed vs Avgs
Here
13.9%
US
19.5%
CA
13.7%
Orange
12.8%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility9.2%
Better than Avg
Here
9.2%
US
14.4%
CA
10.4%
Orange
9.6%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility99.4%
Better than Avg
Here
99.4%
US
79.8%
CA
93.2%
Orange
94.6%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
81.8%
CA
94.2%
Orange
95.4%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.8%
Better than Avg
Here
0.8%
US
1.6%
CA
1.5%
Orange
1.9%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

28deficiencies
Well above state avg (15.4)
37 complaint-triggered

Gordon Lane Care Center shows concerning patterns with 39 complaint-triggered deficiencies indicating families have filed multiple reports about care quality. The facility has recurring problems with medication management, infection control, and resident rights that persist across surveys. While all deficiencies are reportedly corrected, the high volume of complaints and repeated violations across the same care areas suggest ongoing operational challenges families should carefully evaluate before visiting.

Aug 4, 2025Routine
27
0345Potential for harm · WidespreadCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0557Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

0558Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

0578Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

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.

0628Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

0645Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

0693Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

0694Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0697Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

0698Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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

0757Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

0761Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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.

0813Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

0838Potential for harm · IsolatedCorrected

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

0842Potential for harm · IsolatedCorrected

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.

0849Potential for harm · IsolatedCorrected

Administration Deficiencies

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.

0909Potential for harm · IsolatedCorrected

Environmental Deficiencies

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

0161Potential for harm · IsolatedCorrected

Construction Deficiencies

Use approved construction type or materials.

0324Potential for harm · IsolatedCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0550Minimal · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Aug 4, 2025Complaint
2
0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0881Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Jun 18, 2025Complaint
1
0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Jun 2, 2025Complaint
2
0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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

Feb 5, 2025Complaint
1
0761Minimal · PatternCorrected

Pharmacy Service Deficiencies

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.

Nov 21, 2024Complaint
2
0657Minimal · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0880Minimal · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Ownership & Operations

Who Operates This Facility

Owner / Operator

Gordon Lane Care Center

Organization Type

for profit

Chain Affiliation

Chain Name

David Johnson

Chain Size

46 facilities nationwide

Chain avg rating: 3.2/5 · Rank 35 of 45

Ownership & Management

Owners

Gordon Lane Healthcare LLC

Owner · Organization

100%

Key personnel

Johnson, FrankManaging Control - Governing BodyGordon Lane Healthcare LLCManagerSun Mar Management ServicesManagerDehghanmanesh, AdrianManagerFarrales, MaryManager
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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