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Rosecrans Care Center at a glance: owner, beds and ratings
* 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 ↗
Rosecrans Care 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.
| Date | Source | Finding | Record |
|---|---|---|---|
| April 3, 2026 | State (CDPH) | Class B citation (Abuse/Facility Not Self Reported), penalty $2,400, appealed by the facility Abuse | Government record (CDPH) ↗ |
| February 27, 2026 | Federal (CMS-2567), Complaint | F609 – Reporting of Alleged Violations, severity D (no actual harm, potential for more than minimal harm, isolated) Abuse | Government record (CDPH) ↗ |
| November 26, 2025 | State (CDPH) | Class B citation (Abuse/Facility Not Self Reported), penalty $2,550, appealed by the facility Abuse | Government record (CDPH) ↗ |
| January 16, 2025 | State (CDPH) | Administrative Penalty (DHPPD: 2 – 11 Days), penalty $25,000 | Government record (CDPH) ↗ |
| May 2, 2024 | State (CDPH) | Class B citation (Abuse/Facility Not Self Reported), penalty $3,000 Abuse | Government record (CDPH) ↗ |
| March 14, 2024 | Federal (CMS-2567), Complaint | F609 – Reporting of Alleged Violations, severity D (no actual harm, potential for more than minimal harm, isolated) F689 – Free of Accident Hazards/Supervision/Devices, severity G (actual harm, one or a few residents) AbuseFalls / supervision › Read what inspectors found ↓ | Government record (CDPH) ↗ |
| March 4, 2024 | Federal (CMS-2567), Complaint | F689 – Free of Accident Hazards/Supervision/Devices, severity G (actual harm, one or a few residents) Falls / supervision › Read what inspectors found ↓ | Government record (CDPH) ↗ |
What inspectors found at Rosecrans Care Center
Tap a finding to read the summary. Each one is written from the government report linked under it.
March 2024: F689 (severity G) and F609 (severity D) after a resident who needed two-person care had a broken arm
The 2567 report states Resident 1 had quadriplegia (inability to move the body below the neck), contractures (stiff, shortened muscles and joints) in several joints, and aphasia (a language disorder from brain damage). According to the report, her January 2024 assessment said she needed two or more staff for bed mobility, transfers, toileting, showers and personal hygiene. Inspectors found her care plans did not include two-person assistance.
Inspectors found that on February 28, 2024, CNA 1 gave Resident 1 her morning bed bath alone and noticed discoloration on her right arm and that she seemed to be in pain. CNA 1 told inspectors she had always done the resident's daily care alone without asking for help. A licensed vocational nurse told inspectors an aide reported a baseball-size bruise and that it was suspicious for a resident who did not move to have a bruise on top of the arm. The director of nursing told inspectors she did not know aides were bathing, turning and moving Resident 1 without a second person, and that residents who depend on staff for care were supposed to have two staff to prevent injuries.
According to the report, an X-ray that day showed a non-displaced fracture (a break with the bone still in line) of the upper arm bone near the shoulder. Resident 1 was taken to an acute care hospital, where her arm was swollen, and she returned to the facility in a sling on March 1, 2024. The facility was cited under F689 (accident hazards and supervision) at severity G and F609 (reporting of alleged violations) at severity D.
March 2024: F689 (severity G) after a resident at risk of wandering left the building and was found injured
The 2567 report states Resident 1 was admitted in February 2024 with dementia, repeated falls, difficulty walking and weakness on one side of the body. According to the report, his assessment showed severely impaired decision-making, and on February 7, 2024, staff recorded that he wandered and tried to leave the facility unattended. His February 13 care plan identified him as at risk for elopement (leaving without staff knowledge) and said he would be monitored. The administrator told inspectors he knew Resident 1 wandered and had been given a wander guard (an alarm bracelet).
Inspectors found the facility did not supervise Resident 1 or monitor its exit doors. According to the report, the administrator and director of nursing reviewed video with inspectors showing that on February 22, 2024, Resident 1 pushed a wheelchair past the east nursing station, where two nursing staff were sitting, and went out the east door at 6:12 p.m. About a minute later, the desk nurse opened and shut the door without looking outside. The receptionist told inspectors the nurse asked her for help turning off the ringing door alarm and did not know Resident 1 had left.
According to the report, paramedics found Resident 1 on a road at 7:23 p.m. with a head injury and a 2-centimeter cut on his forehead. A CT scan at a hospital showed a trace subarachnoid hemorrhage (bleeding in the space around the brain), and he was moved to a second hospital for a higher level of care. The facility was cited under F689 at severity G.
Complaints against Rosecrans Care Center
| Year | Intakes | Complaints | Facility-reported incidents | Substantiated (at least one allegation) |
|---|---|---|---|---|
| 2023 | 13 | 8 | 5 | 5 |
| 2024 | 8 | 5 | 3 | 6 |
| 2025 | 16 | 11 | 5 | 6 |
| 2026 | 21 | 11 | 10 | 2 |
Cal Health Find lists 58 complaint and facility-reported incident intakes for this facility from 2023 through October 30, 2026. CDPH substantiated at least one allegation in 19 of them. 21 intakes involved an allegation in CDPH’s abuse category, and 3 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.
Sexual abuse reports at Rosecrans Care Center
Cal Health Find lists 1 intake for Rosecrans Care Center from 2023 through October 30, 2026 that included an allegation CDPH classified as sexual abuse (0 from complaints and 1 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.
| Year | Intakes with a sexual abuse allegation | Substantiated |
|---|---|---|
| 2026 | 1 | 0 |
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 →
Rosecrans Care Center lawsuits and criminal cases
Our search of California Attorney General and Los Angeles County District Attorney announcements, court reports and news coverage for Rosecrans Care Center is not finished yet. This section will be updated when it is; until then, do not read the absence of a case here as a finding that none exists.
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.
What to do now
- If someone is in danger, call 911.
- File a complaint with CDPH about Rosecrans Care Center: CDPH complaint form ↗
- Contact the long-term care ombudsman, the state-funded advocate for nursing home residents: California Long-Term Care Ombudsman ↗
- Ask the facility in writing for a copy of the resident’s chart, and write down dates, names of staff on shift, and photos of any injury.
- Talk to a Los Angeles nursing home abuse lawyer →
Free nursing home case review
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Questions families ask
Has Rosecrans Care Center been cited by the State of California?
Cal Health Find lists 5 state citations for Rosecrans Care Center since 2023, including 0 Class AA and 0 Class A. Each one is listed in the timeline above with a link to the CDPH record.
How many complaints have been filed against Rosecrans Care Center?
From 2023 through October 30, 2026, Cal Health Find lists 58 complaint and facility-reported incident intakes, and CDPH substantiated at least one allegation in 19 of them.
Does Medicare flag Rosecrans Care Center for abuse?
As of our data date, Medicare Care Compare does not show its abuse icon for Rosecrans Care Center. The icon is only one signal; read the citations above.
Have there been sexual abuse reports at Rosecrans Care Center?
Cal Health Find lists 1 complaint or facility-reported incident intake at Rosecrans Care 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 Rosecrans Care 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 Rosecrans Care Center have?
Rosecrans Care Center is licensed by CDPH for 113 beds and has a CMS overall rating of 3 out of 5 stars.
Who owns or operates Rosecrans Care Center?
CDPH lists the licensee as HEALTHCARE INVESTMENTS, INC.. CMS does not list a chain for this facility.
My parent was hurt at Rosecrans Care 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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Hurt at Rosecrans Care Center? — Beverly Law
If your loved one was hurt at Rosecrans Care Center, talk to a California elder abuse attorney. Free, confidential, English or Spanish. You pay no fees and no costs unless we win.
Other nursing homes near Rosecrans Care Center
| Facility | City | Distance | CMS stars | Class AA/A | Federal G–L |
|---|---|---|---|---|---|
| Gardena Convalescent Center | Gardena | 0.4 mi | 3/5 | 1 | 0 |
| Kei-Ai South Bay Healthcare Center | Gardena | 0.5 mi | 2/5 | 2 | 2 |
| Memorial Hospital of Gardena D/P SNF | Gardena | 0.6 mi | 4/5 | 0 | 1 |
| Clear View Sanitarium | Gardena | 1.3 mi | 5/5 | 0 | 0 |
| Clear View Convalescent Center | Gardena | 1.3 mi | 5/5 | 0 | 0 |
| Las Flores Convalescent Hospital | Gardena | 1.5 mi | 1/5 | 3 | 5 |
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
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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