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Nursing HomeMedicaid Investigative

Monte Vista Healthcare Center

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

802 Buena Vista Street, Duarte, CA 9101069 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
3.9/5

based on 35 Google reviews

5
4
3
2
1
Monte Vista Healthcare Center Nursing Home in Duarte, CA — Street View
Street View

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5/ 10
high 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)
  • Low staffing rating (2/5 stars)
  • Above-median deficiencies (24 vs median 13.0)
  • High RN turnover (56%)

Below average in CA · Critically understaffed (RN) · Below chain average · $10,488 in fines

Source: Medicare data

What this means for your family

This facility offers a very warm, clean, and culturally inclusive environment with highly praised nursing assistants. However, families must be extremely vigilant regarding medication management and ensure that the facility can meet your loved one's specific clinical needs, as there are documented instances of inadequate care for complex cases.

Google Reviews

Google Reviews

35 reviews on Google
Families considering Monte Vista Healthcare Center will find a facility praised for its compassionate nursing staff, particularly the CNAs, and its welcoming, clean environment. However, there are serious, recurring allegations regarding inadequate care, including instances of patients being left without food, water, or hygiene assistance, and concerns about the facility's ability to manage complex medication needs.

Quality Themes

Tap a score for details
Food5.0Staff6.0Clean9.0Activities7.0Meds1.0MemoryN/AComms7.0ValueN/A

Strengths

  • Compassionate and attentive nursing staff
  • Clean and well-maintained facilities
  • Welcoming atmosphere for Spanish-speaking residents
  • Effective physical therapy and rehabilitation services

Concerns

  • Neglect regarding basic needs like feeding and hygiene (mentioned by 2 reviewers)
  • Inability to manage complex medication or medical needs (mentioned by 2 reviewers)
  • Staffing shortages and overworked employees (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'14(1)'19(3)'21(3)'24(1)'26(6)

Distribution · 39 analyzed

5
26
4
0
3
2
2
1
1
10

How They Respond to Reviews

0%response rate
Generic

The owner uses highly templated responses, employing a standard script for 5-star ratings and a scripted, professional template to deflect negative feedback toward a phone call.

Questions for Your Tour

  • 1I noticed some wonderful comments about the compassionate nursing staff and the welcoming atmosphere for Spanish-speaking families; how do you ensure that personalized care remains a priority for every resident?
  • 2With the recent inspections, what specific steps is the facility taking to improve staffing levels and ensure employees aren't feeling overwhelmed?
  • 3How does the nursing team manage complex medication schedules and ensure that every dose is administered accurately and on time?
  • 4Can you walk me through your protocols for ensuring basic daily needs, like meal assistance and personal hygiene, are consistently met for every resident?
  • 5What is the process for handling medical emergencies or sudden changes in a resident's health during the night or over the weekend?
  • 6What kind of daily activities or social programs do you have in place to keep the residents engaged and active within the community?

Personalized based on this facility's data


Key Review Excerpts

The nurses truly care about their patients and treat everyone with kindness and respect. You can feel the compassion in the way they provide care.

Long-term resident's family · 2026★★★★★

My Grandmother stayed for rehabilitation. This facility is very clean the CNAS are very nice and caring.

Rehab patient's family · 2025★★★★★

My mother was admitted today and she was left lying there with no food or water or care of any kind (bathroom?) for 7.5 hours until my brother came in to help her himself.

Long-term resident's family · 2022☆☆☆☆
Source: 35 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.36hrs
48%
Registered nurses for medical care
Total Nursing
4.19hrs
OK
All nurses + aides combined
Staff Turnover
44%
Lower is better (< 30% = good)
RN Turnover
43%
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
3/ 5
Better Than Avg

11

measures

Worse Than Avg

2

measures

Mixed Results

4

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility2.2%
Better than Avg
Here
2.2%
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 Facility5.6%
Better than Avg
Here
5.6%
US
15.5%
CA
11.7%
Los angeles
11.4%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility9.9%
Better than Avg
Here
9.9%
US
19.5%
CA
13.7%
Los angeles
10.8%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility10.0%
Mixed vs Avgs
Here
10.0%
US
19.4%
CA
10.7%
Los angeles
9.7%
💉

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%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility10.4%
Mixed vs Avgs
Here
10.4%
US
15.3%
CA
10.5%
Los angeles
9.5%
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 Facility99.6%
Better than Avg
Here
99.6%
US
81.8%
CA
94.2%
Los angeles
94.5%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility2.0%
Worse than Avg
Here
2.0%
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

27deficiencies
2penalties
Well above state avg (15.4)
8 complaint-triggered
$10,488 in fines

Recent complaint investigations revealed serious concerns about abuse reporting and resident care that remain uncorrected as of January 2026. The facility has persistent issues across multiple surveys with medication management, food safety, infection control, and safety systems. While most routine inspection violations show correction dates, the unresolved complaint-triggered deficiencies regarding abuse reporting and treatment failures are significant red flags requiring thorough investigation before placement.

Mar 4, 2026Complaint
2
0656Potential for harm · PatternCorrected

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.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Feb 17, 2026Complaint
1
0607Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Jan 9, 2026Complaint
3
0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Jul 23, 2025Complaint
2
0812Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0814Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

Feb 21, 2025Routine
23
0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0584Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor 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.

0684Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

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

0686Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

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

0695Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

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

0759Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0761Potential for harm · 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.

0803Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

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.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0921Potential for harm · PatternCorrected

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

0351Potential for harm · PatternCorrected

Smoke Deficiencies

Install an approved automatic sprinkler system.

0920Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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

0554Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

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.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

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.

0804Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

0919Potential for harm · IsolatedCorrected

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

0925Potential for harm · IsolatedCorrected

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

0923Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Feb 11, 2024Routine
13
0037Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Establish staff and initial training requirements.

0345Potential for harm · WidespreadCorrected

Smoke Deficiencies

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

0656Potential for harm · PatternCorrected

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.

0677Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0685Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

0759Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0223Potential for harm · PatternCorrected

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

0271Potential for harm · PatternCorrected

Egress Deficiencies

Have exits that are accessible at all times.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0732Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0342Potential for harm · IsolatedCorrected

Smoke Deficiencies

Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

0920Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Federal Penalties

Fine

Jun 26, 2023

$2,797

Fine

Jun 20, 2023

$2,447

Ownership & Operations

Who Operates This Facility

Owner / Operator

Monte Vista Healthcare Center

Organization Type

for profit

Chain Affiliation

Chain Name

Cambridge Healthcare Services

Chain Size

32 facilities nationwide

Chain avg rating: 2.6/5 · Rank 16 of 31

Ownership & Management

Owners

Win Win Enterprises, LLC

Owner · Organization

45%

Key personnel

Lawler, EmelynManaging Control - Governing BodyVidales, MiguelManaging Control - Governing BodyWintner, JacobOfficer / DirectorCambridge Healthcare Services LLCManagerButenko, JulieManager
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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