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Nursing HomeMedicaid Investigative

Royal Gardens Healthcare

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

2339 W. Valley Blvd., Alhambra, CA 9180343 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
2.6/5

based on 17 Google reviews

5
4
3
2
1
Royal Gardens Healthcare Nursing Home in Alhambra, CA — Street View
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4/ 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 (23 vs median 13.0)
  • High staff turnover (53%)

Below average in CA · Meets national RN staffing standard · Above recommended total nurse staffing · No penalties on record

Source: Medicare data

What this means for your family

While some individual caregivers are noted for their compassion, the facility has significant, documented issues with medical neglect and unresponsiveness. If you choose this facility, you must implement a rigorous daily check-in schedule to ensure meals are being served and hygiene needs are being met.

Google Reviews

Google Reviews

17 reviews on Google
Families should approach this facility with significant caution due to serious allegations regarding patient neglect, including missed meals, unaddressed pressure sores, and lack of emergency response. While some individual CNAs are praised for their kindness and attentiveness, there are recurring reports of poor communication and staff unresponsiveness to both patients and families.

Quality Themes

Tap a score for details
Food1.0Staff3.0Clean3.0Activities5.0MedsN/AMemoryN/AComms1.0ValueN/A

Strengths

  • Compassionate individual CNAs
  • Clean and fresh environment
  • Efficient nursing teamwork

Concerns

  • Neglect regarding basic care and hygiene (mentioned by 2 reviewers)
  • Unresponsive staff and poor communication (mentioned by 3 reviewers)
  • Lack of urgency in medical emergencies (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'11(1)'20(1)'22(4)'24(2)'26(1)

Distribution · 20 analyzed

5
6
4
0
3
1
2
1
1
12

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1I noticed some families have mentioned how compassionate the CNAs are here; how do you ensure that level of personal care is maintained for every resident?
  • 2With the recent inspections, what specific steps has the facility taken to address and resolve the noted deficiencies?
  • 3How does the nursing team coordinate communication with families to ensure we are always kept in the loop regarding changes in a loved one's health?
  • 4What is the current process for ensuring residents receive timely assistance with personal hygiene and daily grooming?
  • 5Can you tell me more about the dining experience and how the facility is working to improve the variety and quality of the meals served?
  • 6In the event of a sudden medical change or an after-hours emergency, what is the specific protocol for ensuring a rapid and urgent response?

Personalized based on this facility's data


Key Review Excerpts

Although he was not there long I saw them be so attentive and so kind to my father, Carol, and Maria. They helped patients not assigned to them and was always gentle and kind with her words.

Long-term resident's family · 2024★★★★★

We received a call from a nurse/cna on the 3rd day that my brother was there. Telling us he wouldn't wake up. This was at 10 am, my brother was given medication but not fed breakfast. We call they never answer.

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

I rushed to the front desk and a woman there said she's not a nurse so she cannot do anything. She didn't even try to contact her co-workers to help the patient, she just pointed to room 107 with a nurse in it and told me to talk to her.

Visitor · 2019☆☆☆☆
Source: 17 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
1.21hrs
OK
Registered nurses for medical care
Total Nursing
4.41hrs
OK
All nurses + aides combined
Staff Turnover
57%
Lower is better (< 30% = good)
RN Turnover
50%
Lower is better (< 30% = good)

This facility meets the national staffing benchmarks. Higher staffing is linked to fewer falls and better day-to-day care.

Quality Measures

Quality Measures

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

Medicare Rating
4/ 5
Better Than Avg

6

measures

Worse Than Avg

3

measures

Mixed Results

8

measures

Long-Stay Residents
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility19.9%
Worse than Avg
Here
19.9%
US
19.4%
CA
10.7%
Los angeles
9.7%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility19.8%
Worse than Avg
Here
19.8%
US
19.5%
CA
13.7%
Los angeles
10.8%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility8.8%
Better than Avg
Here
8.8%
US
15.5%
CA
11.7%
Los angeles
11.4%
😔

Residents with depression symptoms

↓ Lower is better
This Facility11.8%
Mixed vs Avgs
Here
11.8%
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 vaccinated for pneumonia

↑ Higher is better
This Facility97.7%
Mixed vs Avgs
Here
97.7%
US
93.4%
CA
98.6%
Los angeles
99.1%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility12.4%
Mixed vs Avgs
Here
12.4%
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 Facility81.6%
Mixed vs Avgs
Here
81.6%
US
79.8%
CA
93.2%
Los angeles
92.5%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility83.4%
Mixed vs Avgs
Here
83.4%
US
81.8%
CA
94.2%
Los angeles
94.5%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
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

33deficiencies
Well above state avg (15.4)
26 complaint-triggered

Royal Gardens Healthcare has a concerning pattern of ongoing issues, with families filing multiple complaints triggering federal investigations. The facility shows recurring problems with medication management, infection control, and pressure ulcer care across multiple years. While most deficiencies are eventually corrected, several serious violations from early 2024 regarding abuse prevention and resident grievances remain unaddressed by the facility.

Apr 16, 2026Complaint
5
0684Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

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

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0558Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

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.

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.

Apr 9, 2026Complaint
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.

Apr 8, 2026Complaint
1
0691Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Jan 23, 2026Routine
20
0761Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

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.

0686Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

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

0726Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

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.

0757Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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

0759Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

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.

0558Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

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.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0679Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

0688Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide 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.

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.

0810Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

0814Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

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.

0321Potential for harm · IsolatedCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0355Potential for harm · IsolatedCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

0912Minimal · PatternCorrected

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Jan 23, 2026Complaint
4
0585Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

0607Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

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.

Jan 13, 2026Complaint
1
0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Ownership & Operations

Who Operates This Facility

Owner / Operator

Royal Gardens Healthcare

Organization Type

for profit

Chain Affiliation

Chain Name

Serrano Group

Chain Size

11 facilities nationwide

Chain avg rating: 2.3/5 · Rank 9 of 11

Ownership & Management

Owners

Gardens Licensee 4 LLC

Owner · Organization

100%

Bin Mendel LLC

Owner (parent company) · Organization

Bl Cali Partners LLC

Owner (parent company) · Organization

Js Fenton LLC

Owner (parent company) · Organization

Rgf Consulting LLC

Owner (parent company) · Organization

Serrano Group LLC

Owner (parent company) · Organization

Serrano Partners LLC

Owner (parent company) · Organization

Yaame LLC

Owner (parent company) · Organization

Fensterman, Howard

Owner (parent company)

Fensterman, Jordan

Owner (parent company)

Fensterman, Robert

Owner (parent company)

Jacobs, Dov

Owner (parent company)

Leibson, Staci

Owner (parent company)

Taub, Judah

Owner (parent company)

Key personnel

Jacobs, DovOfficer / DirectorGardens Licensee 4 LLCManagerYu, ArmandoManager
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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