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NURSING HOME INSPECTION REPORT

West Covina Healthcare Center in West Covina: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

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Published by Beverly Law
850 S Sunkist Ave, West Covina · CDPH and CMS records · English y Español
Cal Health Find, the California Department of Public Health (CDPH) database, lists 7 state citations for West Covina Healthcare Center since 2023, including 0 Class AA and 2 Class A, and 3 federal deficiencies that inspectors rated at the actual-harm level or higher (G through L). The most serious state action was a Class A citation (Patient Care), penalty $20,000, appealed by the facility, issued March 12, 2024. The federal Medicare Care Compare site does not show its abuse icon for this facility as of our data date. Cal Health Find also lists 8 complaint or incident reports since 2023 that included a sexual abuse allegation; CDPH substantiated 0.

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West Covina Healthcare Center at a glance: owner, beds and ratings

Address
850 S Sunkist Ave, West Covina, CA 91790
CDPH license / facility ID
950000014 / 950000049
Medicare CCN
055992
Licensed beds
97
Licensee (CDPH)
AG WEST COVINA, LLC
Chain / affiliated entity (CMS)
Cambridge Healthcare Services (chain or affiliated entity listed by CMS)
Administrator of record
Baltazar, Eileen N
CMS overall rating
2 of 5 stars
CMS staffing rating
3 of 5 stars
Nurse staffing (CMS)
4.03 reported nurse hours per resident per day*
CMS fines (last 3 years)
$44,027
CMS abuse icon
Not shown

* California separately requires at least 3.5 direct care service hours per patient day, counted under state rules, so the two numbers are not measured the same way.

Records: Cal Health Find ↗ · Medicare Care Compare ↗

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West Covina Healthcare Center citations and inspection findings

Newest first. State citations come from CDPH; federal deficiencies come from the CMS-2567 inspection report CDPH writes for Medicare. Every row links to the government record.

DateSourceFindingRecord
August 27, 2026State (CDPH)Class B citation (Medication), penalty $3,000Government record (CDPH) ↗
April 3, 2025State (CDPH)Administrative Penalty (DHPPD: 12 – 24 Days), penalty $50,000Government record (CDPH) ↗
December 27, 2024Federal (CMS-2567), ComplaintF609 – Reporting of Alleged Violations, severity D (no actual harm, potential for more than minimal harm, isolated)
Abuse
Government record (CDPH) ↗
March 28, 2024Federal (CMS-2567), ComplaintF760 – Residents are Free of Significant Med Errors, severity G (actual harm, one or a few residents)
Read what inspectors found ↓
Government record (CDPH) ↗
March 12, 2024State (CDPH)Class A citation (Patient Care), penalty $20,000, appealed by the facility
Read what inspectors found ↓
Government record (CDPH) ↗
January 29, 2024Federal (CMS-2567), ComplaintF656 – Develop/Implement Comprehensive Care Plan, severity G (actual harm, one or a few residents)
Read what inspectors found ↓
Government record (CDPH) ↗
November 15, 2023State (CDPH)Class A citation (Patient Care), penalty $25,000
Read what inspectors found ↓
Government record (CDPH) ↗
October 10, 2023Federal (CMS-2567), CertificationF686 – Treatment/Svcs to Prevent/Heal Pressure Ulcer, severity G (actual harm, one or a few residents)
Pressure injury ›
Read what inspectors found ↓
Government record (CDPH) ↗
August 7, 2023Federal (CMS-2567), ComplaintF609 – Reporting of Alleged Violations, severity D (no actual harm, potential for more than minimal harm, isolated)
Abuse
Government record (CDPH) ↗
February 24, 2023Federal (CMS-2567), ComplaintF607 – Develop/Implement Abuse/Neglect Policies, severity D (no actual harm, potential for more than minimal harm, isolated)
Abuse
Government record (CDPH) ↗

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What inspectors found at West Covina Healthcare Center

Tap a finding to read the summary. Each one is written from the government report linked under it.

·
March 2024: F760 (severity G) after a nurse gave a resident Narcan nasal spray instead of an allergy spray

According to the federal 2567 report, on March 14, 2024, at about 7 p.m., LVN 1 gave Resident 1 Narcan nasal spray (naloxone, a drug that reverses an opioid overdose) instead of the prescribed Flonase (fluticasone, an allergy nasal spray). Inspectors found LVN 1 did not check the label three times to confirm the right drug, dose and time, as the facility's policy requires. Resident 1 had intact cognition and had orders for both sprays and for Percocet, an opioid pain medicine, as needed.

Resident 1 told inspectors the spray looked unfamiliar and that Resident 1 told LVN 1 it was the wrong medication, but LVN 1 insisted. According to the report, right after the spray Resident 1 shouted, complained of chest pain and burning over the body, and said it felt like dying. Resident 1 told inspectors about vomiting and urinating during the reaction. Resident 1 was sent by 911 to an acute care hospital and treated for acute opioid withdrawal (sudden withdrawal symptoms) caused by the accidental Narcan dose. Resident 1 said chest pain and tingling continued after returning.

LVN 1 told inspectors that LVN 1 did not check the label before giving the spray and thought it was the Flonase. The report states the facility failed to keep Resident 1 free of a significant medication error. Inspectors cited F760 (residents are free of significant medication errors) at severity G.

↑ Back to this finding in the timeline

March 2024: Class A citation and F656 (severity G) after a 104-year-old resident fell during a bed bath and fractured her hip

According to the citation, CDPH made a visit on January 29, 2024, to investigate a complaint about care, safety and falls. Resident 1 was a 104-year-old woman with dementia, muscle weakness and osteoporosis (weak, brittle bones). Her care plan said she needed physical help from two people for bed mobility, and an assessment showed she depended on staff to roll side to side.

CDPH found that on December 12, 2023, at 10:30 a.m., CNA 1 turned her onto her side alone while bathing her in bed. According to progress notes cited by the department, she turned the opposite way from CNA 1's instruction and rolled off the bed to the floor. She had right hip pain, and a physician ordered an immediate X-ray. The citation states the X-ray provider had not arrived by 7:41 p.m., and she was sent to an acute care hospital by non-emergency transport at 8:15 p.m. The citation states she sustained a displaced fracture of the right femoral neck (the top of the thighbone). She had a partial hip replacement (hemiarthroplasty) on December 14 and stayed five days.

The department determined the facility failed to carry out her care plan and its own fall and care plan policies. CDPH issued a Class A citation with a $25,000 penalty; state records show it was appealed and list a final penalty of $20,000. The federal 2567 report cited F656 (develop and implement a comprehensive care plan) at severity G.

↑ Back to this finding in the timeline

November 2023: Class A citation and F686 (severity G) after a resident developed pressure injuries on the heel and buttocks

According to the citation, CDPH conducted a recertification survey on October 10, 2023. Resident 22, an 86-year-old man with diabetes, was admitted on September 2, 2023, without pressure injuries and was rated at high risk for pressure ulcers (bed sores). His care plan called for staff to check his skin and report redness or open areas.

CDPH found the facility did not assess his skin on the buttocks, tailbone, sacral area and feet, did not float (raise) his heels with a pillow as his care plan required, and did not apply heel protectors during the day shift as a physician ordered on October 2. On October 10, inspectors saw him four times on his back with both heels resting directly on the pillow, and no heel protectors until 2:20 p.m., when one was on the left foot only. He told inspectors he was not turned every two hours and did not refuse turning. CNA 1 told inspectors she had not been told he needed turning every two hours.

The department determined he developed an avoidable Stage 3 pressure ulcer (full-thickness skin loss) on the back of the left heel, noted October 1, and an avoidable deep tissue pressure injury (damage under intact skin, seen as deep red or purple discoloration) on the buttocks and tailbone area on October 13, 2023. CDPH issued a Class A citation with a $25,000 penalty. The federal 2567 report cited F686 (treatment and services to prevent and heal pressure ulcers) at severity G.

↑ Back to this finding in the timeline

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Complaints against West Covina Healthcare Center

YearIntakesComplaintsFacility-reported incidentsSubstantiated (at least one allegation)
202315877
2024292099
2025356294
20262910190

Cal Health Find lists 108 complaint and facility-reported incident intakes for this facility from 2023 through October 30, 2026. CDPH substantiated at least one allegation in 20 of them. 63 intakes involved an allegation in CDPH’s abuse category, and 7 of those had an abuse allegation substantiated. An intake can contain several allegations; “unsubstantiated” means CDPH did not find enough evidence, not that nothing happened.

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Sexual abuse reports at West Covina Healthcare Center

Cal Health Find lists 8 intakes for West Covina Healthcare Center from 2023 through October 30, 2026 that included an allegation CDPH classified as sexual abuse (1 from complaints and 7 reported by the facility itself). CDPH substantiated a sexual abuse allegation in 0 of them. Federal rules require a nursing home to report an abuse allegation to the state within two hours, so a facility-reported incident means staff raised the allegation, not that it was proven. “Unsubstantiated” means CDPH did not find enough evidence; it does not mean nothing happened.

YearIntakes with a sexual abuse allegationSubstantiated
202310
202430
202640

Warning signs include bruising or bleeding in the genital area or inner thighs, a new genital infection, torn or stained underclothing, and a resident who suddenly fears a particular staff member or resists being bathed or changed. If you suspect sexual abuse, call 911 or local police first, ask that the resident not be bathed before a medical exam, and then report it to CDPH and the long-term care ombudsman. Sexual abuse reports at Los Angeles County nursing homes →

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West Covina Healthcare Center lawsuits and criminal cases

We searched California Attorney General and Los Angeles County District Attorney announcements and news coverage for West Covina Healthcare Center and its licensee and found no public criminal case or civil lawsuit we could tie to this facility as of October 30, 2026. Many civil cases settle quietly or are not covered by the press, so this is not a complete court search.

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What this record means for your family

California uses classes for state citations. Under Health and Safety Code section 1424 ↗, a Class AA citation is a Class A violation that CDPH determined was a direct proximate cause of a resident’s death. A Class A citation means CDPH found an imminent danger, or a substantial probability, that death or serious physical harm would result. Class B covers violations with a direct or immediate relationship to residents’ health, safety or security.

Federal deficiencies carry a letter from A to L. G, H and I mean inspectors found actual harm to residents; J, K and L mean immediate jeopardy, the most serious level. F600 is the federal rule that residents be free from abuse and neglect; F609 and F610 cover reporting and investigating allegations; F689 covers accidents and supervision; F686 covers pressure injuries.

Warning signs worth asking about: unexplained bruises or fractures, new bed sores, sudden weight loss or dehydration, a resident who becomes fearful or withdrawn around certain staff, and calls that go unanswered.

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What to do now

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Questions families ask

Has West Covina Healthcare Center been cited by the State of California?

Cal Health Find lists 7 state citations for West Covina Healthcare Center since 2023, including 0 Class AA and 2 Class A. Each one is listed in the timeline above with a link to the CDPH record.

How many complaints have been filed against West Covina Healthcare Center?

From 2023 through October 30, 2026, Cal Health Find lists 108 complaint and facility-reported incident intakes, and CDPH substantiated at least one allegation in 20 of them.

Does Medicare flag West Covina Healthcare Center for abuse?

As of our data date, Medicare Care Compare does not show its abuse icon for West Covina Healthcare Center. The icon is only one signal; read the citations above.

Have there been sexual abuse reports at West Covina Healthcare Center?

Cal Health Find lists 8 complaint or facility-reported incident intakes at West Covina Healthcare Center since 2023 that included an allegation CDPH classified as sexual abuse, and CDPH substantiated 0. The section above breaks them down by year.

Where can I read reviews and complaints about West Covina Healthcare Center?

Online reviews are opinions. The official record is the state and federal inspection file: this page summarizes it and links each citation, complaint outcome and inspection report on Cal Health Find and Medicare Care Compare, so you can read the source yourself.

How many beds does West Covina Healthcare Center have?

West Covina Healthcare Center is licensed by CDPH for 97 beds and has a CMS overall rating of 2 out of 5 stars.

Who owns or operates West Covina Healthcare Center?

CDPH lists the licensee as AG WEST COVINA, LLC. CMS lists the facility under the chain or affiliated entity Cambridge Healthcare Services.

My parent was hurt at West Covina Healthcare Center. What should I do?

Get medical care first, then report it to CDPH and the long-term care ombudsman, ask for the chart in writing and keep notes and photos. For a free, confidential review of a possible case, call Beverly Law at (310) 552-6959.

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Other nursing homes near West Covina Healthcare Center

FacilityCityDistanceCMS starsClass AA/AFederal G–L
West Covina Medical Center D/P SNFWest Covina0.2 mi4/500
West Haven HealthcareWest Covina0.5 mi4/510
Victoria Care CenterBaldwin Park0.6 mi5/500
Garden View Post Acute RehabilitationBaldwin Park0.7 mi4/500
Clara Baldwin Stocker Home for WomenWest Covina1.3 mi3/501
Beacon Healthcare CenterWest Covina1.4 mi5/500

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Methodology and sources

We pulled this facility’s complaints, state enforcement actions and survey deficiencies from Cal Health Find for 2023 through October 30, 2026, downloaded the CDPH citation notices and CMS-2567 reports behind every Class AA or A citation and every federal deficiency at level G or higher, and wrote the summaries above from those documents. Facility details come from the CDPH licensing file and the CMS Provider Data Catalog. Residents are described only as the government documents describe them. See the methodology page to report an error; we review correction requests within five business days.

Sources

  1. Cal Health Find – West Covina Healthcare Center
  2. Medicare Care Compare – West Covina Healthcare Center
  3. CDPH – State Enforcement Actions (open data)
  4. CMS Provider Data Catalog – Nursing homes

Important: This page reports findings from public records of the California Department of Public Health and the Centers for Medicare & Medicaid Services. A citation or deficiency is a regulatory finding by a government agency; it is not a court judgment and not proof of civil or criminal liability. Criminal defendants are presumed innocent unless proven guilty. Lawsuit allegations are claims, not findings. This page is general information, not legal advice, and reading it does not create an attorney-client relationship with Beverly Law. Attorney advertising. Prior results do not guarantee a similar outcome. Data as of: October 30, 2026. Methodology and corrections.

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