Monrovia Gardens Healthcare Center
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 35 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Low overall rating (1/5 stars)
- Low staffing rating (2/5 stars)
- Above-median deficiencies (38 vs median 13.0)
- High staff turnover (62%)
- High RN turnover (67%)
Bottom 25% in CA · Below recommended RN staffing · Above recommended total nurse staffing · Worst in CAMBRIDGE HEALTHCARE SERVICES chain · No penalties on record
What this means for your family
This facility offers excellent physical therapy and a pleasant environment for resident engagement. However, families should closely monitor medical communications and vital sign reporting, as recent reviews indicate significant lapses in nursing oversight and potential staffing shortages.
Google Reviews
Google Reviews
35 reviews on Google“Families may find comfort in the facility's dedicated therapy programs and the presence of a pleasant outdoor garden space. However, there are significant concerns regarding inconsistent nursing quality, potential understaffing, and issues with temperature regulation in the rooms.”
Quality Themes
Tap a score for detailsStrengths
- Effective physical and occupational therapy
- Engaging activities and outdoor garden space
- Supportive and professional administrative staff
- Nutritious and tasty food options
Concerns
- Inconsistent nursing care and monitoring of medical vitals (mentioned by 2 reviewers)
- Staffing shortages and loss of experienced nurses (mentioned by 2 reviewers)
- Uncomfortable room temperatures and overcrowding
Rating Trends
Tap a year to see what changed
Distribution · 37 analyzed
How They Respond to Reviews
Questions for Your Tour
- 1I've heard great things about your physical and occupational therapy programs; could you tell me more about how those are integrated into a resident's weekly routine?
- 2With the beautiful outdoor garden space mentioned by others, how often are residents encouraged to spend time outside for activities?
- 3Could you walk me through your specific protocols for monitoring medical vitals and ensuring consistent nursing oversight throughout the day and night?
- 4What steps is the facility taking to ensure medication management is handled with the highest level of accuracy and safety?
- 5How do you manage staffing levels during busy shifts to ensure that every resident receives attentive, personalized care?
- 6Regarding the comfort of the living spaces, what measures are in place to ensure room temperatures remain stable and comfortable for all residents?
Personalized based on this facility's data
Key Review Excerpts
“The activities dept. provides several activities through out the day and helps to even keep the mind occupied. Having something to do makes getting up and adjusting to the treatment easier.”
“The staffs at Monrovia Garden Healthcare Center are vigilant, helpful, caring, cheerful and professional. They have provided my father with excellent care.”
“My mom lived here for 2 years and I recently brought her home because of her dementia and other red flags. Her blood sugars were over 200 at times over 300. The nurses never bothered to report it to the doctor or show concern until it came to”
Staffing
Staffing Hours
per resident/day · Medicare 2026RN 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
11
measures
2
measures
4
measures
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents whose bladder or bowel control got worse
Residents on anti-anxiety or sleep medication
Residents on antipsychotic medication
Residents vaccinated for pneumonia
Residents needing more daily help over time
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
Families have filed numerous complaints triggering half of Monrovia Gardens' 114 deficiencies across 25 surveys. The facility shows persistent problems with daily care assistance, nursing staffing levels, and resident rights accommodation. Additional recurring issues include infection control, care planning, and medication management. While all deficiencies show correction dates, the pattern of repeated violations in core care areas suggests ongoing operational challenges families should carefully evaluate during visits.
Mar 3, 2026Complaint3
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.
Quality of Life and Care Deficiencies
Provide appropriate foot care.
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Dec 19, 2025Routine22
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
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.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
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.
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.
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Smoke Deficiencies
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Smoke Deficiencies
Install an approved automatic sprinkler system.
Oct 31, 2025Complaint1
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Sep 17, 2025Complaint1
Resident Rights Deficiencies
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Sep 3, 2025Complaint3
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Nutrition and Dietary Deficiencies
Ensure 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.
Aug 27, 2025Complaint1
Environmental Deficiencies
Keep all essential equipment working safely.
Ownership & Operations
Who Operates This Facility
Monrovia Gardens Healthcare Center
for profit
Chain Affiliation
Cambridge Healthcare Services
32 facilities nationwide
Chain avg rating: 2.6/5 · Rank 29 of 31 (Worst)
Ownership & Management
Owners
Ag Facilities Operations, LLC
Owner · Organization
Ira E Smedra Living Trust
Owner (parent company) · Organization
Win Win Enterprises, LLC
Owner (parent company) · Organization
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
35 reviews from families & visitors
Official Website
Visit monroviahcc.com
Medicare data downloads
Original nursing home datasets
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