Is your loved one at St. John of God Retirement and Care Center?
If they fell, developed a bed sore, lost weight, were hurt or abused at St. John of God Retirement and Care Center, leave your name and phone. We call back today, request the chart and the full inspection file, and tell you plainly whether there is a case. Free, confidential, English or Spanish.
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St. John of God Retirement and 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 ↗
St. John of God Retirement and 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 |
|---|---|---|---|
| July 21, 2026 | State (CDPH) | Class B citation (Abuse/Facility Not Self Reported), penalty $3,000 Abuse | Government record (CDPH) ↗ |
| June 11, 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) ↗ |
| April 22, 2025 | State (CDPH) | Class B citation (Abuse/Facility Not Self Reported), penalty $3,000 Abuse | Government record (CDPH) ↗ |
| March 13, 2025 | 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) ↗ |
| July 5, 2024 | State (CDPH) | Class A Trebled citation (Other), penalty $60,000 Read what inspectors found ↓ | Government record (CDPH) ↗ |
| June 12, 2024 | Federal (CMS-2567), Complaint | F600 – Free from Abuse and Neglect, severity D (no actual harm, potential for more than minimal harm, isolated) F607 – Develop/Implement Abuse/Neglect Policies, severity D (no actual harm, potential for more than minimal harm, isolated) Abuse | Government record (CDPH) ↗ |
| May 15, 2024 | State (CDPH) | Class B citation (Abuse/Facility Not Self Reported), penalty $3,000 Abuse | Government record (CDPH) ↗ |
| May 7, 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) ↗ |
| March 22, 2024 | 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) ↗ |
| February 6, 2024 | State (CDPH) | Class A citation (Patient Care), penalty $20,000 Read what inspectors found ↓ | Government record (CDPH) ↗ |
| January 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) ↗ |
| January 3, 2024 | State (CDPH) | Class A citation (Patient Care), penalty $20,000 Read what inspectors found ↓ | Government record (CDPH) ↗ |
Show 5 older findings
| Date | Source | Finding | Record |
|---|---|---|---|
| December 21, 2023 | 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 17, 2023 | 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) ↗ |
| September 26, 2023 | Federal (CMS-2567), Certification | F689 – Free of Accident Hazards/Supervision/Devices, severity J (immediate jeopardy, one or a few residents) Falls / supervision › Read what inspectors found ↓ | Government record (CDPH) ↗ |
| January 12, 2023 | 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) ↗ |
| January 11, 2023 | 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) ↗ |
What inspectors found at St. John of God Retirement and Care Center
Tap a finding to read the summary. Each one is written from the government report linked under it.
July 2024: Class A citation (penalty trebled) and F689 (severity G) after a resident's third fall in eight days
CDPH received a complaint on May 6, 2024, that Resident 1 fell on April 20, April 22 and April 28, 2024, and broke his nose. According to the citation, Resident 1 was a 91-year-old man with dementia, muscle weakness and a history of stroke, who depended on staff for transfers. His fall risk evaluation of April 22, 2024, scored him at high risk for falls.
CDPH found that after the falls on April 20 and April 22, a physician ordered on April 23, 2024, that a soft belt be applied when Resident 1 was up in his wheelchair, to keep him from falling out of it. According to the citation, the facility did not carry out that order, did not follow the care plan that called for the belt, and did not follow its own soft belt policy. Inspectors found the medication administration record from April 23 to April 28 did not show staff monitored the use of a soft belt.
The 2567 report states that on April 28, 2024, a charge nurse saw Resident 1 wheeling himself in the hallway, then heard a thud and found him lying on his right side on the hallway floor, with bleeding and swelling of the nose. The report states the facility's own fall review listed the safety measures in place before that fall, and the soft belt was not among them. According to the citation, Resident 1 had a fracture of the bridge of the nose and was taken to an acute care hospital. CDPH issued a Class A citation with a $20,000 penalty that was trebled to $60,000, and the federal survey cited F689 at severity G.
February 2024: Class A citation and F689 (severity G) after a resident fell alone in a restroom and broke her arm
CDPH received a facility-reported incident on December 28, 2023, about a fall with injury, and made an unannounced visit on January 4, 2024. According to the citation, Resident 1 was a 100-year-old woman with a history of falls, fainting and bleeding in the brain. Her care plans called for staff to help her with walking and toileting, and her December 2023 assessment showed she needed supervision or touching assistance to stand, transfer to the toilet and walk.
CDPH found that on December 27, 2023, at 11:25 p.m., a licensed vocational nurse doing bedside rounds saw Resident 1 alone in the restroom, told her to use the call light when she was done, and continued his rounds. According to the citation, ten minutes later he heard her calling for help and found her face down on the floor. The department determined the facility did not carry out her care plan, did not provide assistance and supervision, and did not follow its own safety and supervision policy. Resident 1 told inspectors she went to the restroom with her walker, felt weak when she stood up and fell forward. The interim director of nursing told inspectors a CNA should have stayed with her and not left her alone.
According to the citation, an X-ray showed a fracture of the lower end of the right upper arm bone (distal humerus). Resident 1 was sent to an acute care hospital on December 28, 2023, with swelling of the right elbow and both knees. CDPH issued a Class A citation with a $20,000 penalty, and the 2567 report states the federal survey cited F689 at severity G.
January 2024: Class A citation and F689 (severity G) after falls by two residents, one with a hip fracture
CDPH received two facility-reported incidents on November 15, 2023, about residents who fell and broke a hip, and made an unannounced visit on November 17, 2023. The citation focuses on Resident 2 and Resident 3. According to the citation, Resident 2 had vascular dementia and age-related osteoporosis (weak bones), used a wheelchair and could not make his own decisions.
CDPH found that after Resident 2 fell on July 24, 2022, his post-fall risk assessment scored him at low risk, although inspectors found the scores did not match his condition and he should have been identified as high risk. According to the citation, the interdisciplinary team recommended steps to prevent more falls, including a wheelchair alarm to alert staff when he got up without help, but his fall care plan was not revised to include them. The department also found the facility did not update Resident 3's care plan with the corrective actions planned after she fell on November 8, 2023.
According to the citation, Resident 2 fell on November 13, 2023, and broke his left hip, with left leg pain and a skin tear on the left ear, and he was hospitalized at an acute care hospital. The citation states Resident 3 fell again on November 20, 2023, 12 days after her earlier fall, and sustained a fracture. CDPH issued a Class A citation with a $20,000 penalty, and the 2567 report states the federal survey cited F689 at severity G.
September 2023: F689 (severity J) over a candle maker and stored items in a resident's room
Inspectors found during a September 2023 survey that the facility did not provide adequate supervision for Resident 92, who had dementia. According to the 2567 report, Resident 92 had bought a candle maker about a year earlier and was using it in her room, without supervision, to make candles and soap. The report states the device could reach temperatures of 196 to 315 degrees Fahrenheit, and the resident said it melted up to 20 pounds of wax.
The 2567 report states the room was cluttered with many items, including storage carts with empty wax containers, a refrigerator, a coffee maker, a heater, two fax machines, drills, craft machines and large containers of food and sodas. Inspectors found the candle maker in a corner with items resting on top of and against it, shelving blocking a window, and food and empty cans on the floor. Inspectors determined this placed Resident 92, her roommate, staff and other residents at risk of serious harm and a possible fire.
According to the report, inspectors told facility leaders on September 30, 2023, that the situation was an immediate jeopardy, meaning noncompliance likely to cause serious harm. The report states the facility removed the candle maker and cleared the room that day, stored the belongings and held a care team meeting with the resident. It also trained staff on signs of hoarding and room and refrigerator checks, and revised the care plan. Inspectors accepted the facility's removal plan on October 2, 2023, and lifted the immediate jeopardy after checking it on site. Inspectors cited F689, the rule on accident hazards and supervision, at severity J.
Complaints against St. John of God Retirement and Care Center
| Year | Intakes | Complaints | Facility-reported incidents | Substantiated (at least one allegation) |
|---|---|---|---|---|
| 2023 | 32 | 12 | 20 | 18 |
| 2024 | 27 | 19 | 8 | 19 |
| 2025 | 15 | 3 | 12 | 4 |
| 2026 | 13 | 2 | 11 | 1 |
Cal Health Find lists 87 complaint and facility-reported incident intakes for this facility from 2023 through October 30, 2026. CDPH substantiated at least one allegation in 42 of them. 28 intakes involved an allegation in CDPH’s abuse category, and 9 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 St. John of God Retirement and Care Center
Cal Health Find lists no complaint or facility-reported incident for St. John of God Retirement and Care Center from 2023 through October 30, 2026 that included an allegation CDPH classified as sexual abuse. That covers only what was reported to the state; if you suspect sexual abuse, report it even if nothing appears here.
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 →
Staffing at St. John of God Retirement and Care Center
Payroll records St. John of God Retirement and Care Center filed with the federal Centers for Medicare & Medicaid Services (CMS) for April through June 2026 show an average of 4.75 nursing hours per resident per day, counting registered nurses (RNs), licensed vocational nurses and nurse aides. The California average CMS published for the same period is 4.54, and the Los Angeles County median is 4.32. RN time averaged 0.36 hours per resident per day (California average 0.68). Staffing averaged 4.27 hours on weekends and 4.94 on weekdays.
CMS reports nursing staff turnover of 30.9% at this facility (California average 36.6%) and RN turnover of 57.1% (California average 37.8%).
California requires most skilled nursing facilities to provide at least 3.5 direct care hours per patient day (Health and Safety Code section 1276.65). Counting the RN, LVN and nurse aide hours in the same payroll data, St. John of God Retirement and Care Center was below 3.5 on 0 of 91 days. This is our calculation from CMS data, not a CDPH finding: CDPH counts some staff differently (for example psychiatric technicians in special treatment programs) and can grant waivers.
| St. John of God Retirement and Care Center | LA County median | California average | |
|---|---|---|---|
| Total nursing hours per resident per day | 4.75 | 4.32 | 4.54 |
| RN hours per resident per day | 0.36 | 0.46 | 0.68 |
| Weekend nursing hours per resident per day | 4.27 | 3.89 | 4.10 |
| Nursing staff turnover | 30.9% | 34.1% | 36.6% |
Compare staffing, profits and fines across Los Angeles County nursing homes →
Who owns St. John of God Retirement and Care Center
The owners and operators below are listed for St. John of God Retirement and Care Center in the federal CMS nursing home ownership file (data as of October 1, 2026). CMS requires each Medicare-certified nursing home to report anyone with a 5% or greater ownership stake and anyone with operational or managerial control.
| Owner or operator | Role | Share | Since |
|---|---|---|---|
| St. John of God Retirement and Care Center | Operational or managerial control | – | December 27, 2024 |
| Bro Michael Bassemier | Operational or managerial control | – | February 1, 2026 |
St. John of God Retirement and Care Center finances
St. John of God Retirement and Care Center reported $26.5 million in health care revenue and net income of $4.2 million for the year ending September 30, 2025, a margin of 16.0%, in its annual financial report to HCAI (as submitted; HCAI has not finished reviewing it). The median operating margin that year was 5.9% for Los Angeles County nursing homes and 6.1% statewide. Medi-Cal paid for 62% of resident days. Salaries for RNs, LVNs and nurse aides came to $6.9 million.
| Year | Revenue | Net income | Margin | Occupancy | Medi-Cal days |
|---|---|---|---|---|---|
| 2023 | $22.7 million | -$1.7 million | -7.7% | 94% | – |
| 2024 | $24.8 million | -$157,375 | -0.6% | 93% | 63% |
| 2025 | $26.5 million | $4.2 million | 16.0% | 94% | 62% |
Federal fines and penalties: St. John of God Retirement and Care Center
CMS lists 2 federal fines totaling $109,529 and 1 Medicare payment denial for St. John of God Retirement and Care Center in the roughly three years its penalty file covers.
| Date | Penalty | Amount or length |
|---|---|---|
| May 22, 2024 | Fine | $14,050 |
| May 22, 2024 | Payment denial | 45 days |
| November 20, 2023 | Fine | $95,479 |
St. John of God Retirement and Care Center lawsuits and criminal cases
We searched California Attorney General and Los Angeles County District Attorney announcements and news coverage for St. John of God Retirement and Care 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.
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 St. John of God Retirement and 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
We read the inspection record and the chart with you and tell you plainly whether there is a case. You pay no fees and no costs unless we win.
Questions families ask
Has St. John of God Retirement and Care Center been cited by the State of California?
Cal Health Find lists 10 state citations for St. John of God Retirement and Care Center since 2023, including 0 Class AA and 3 Class A. Each one is listed in the timeline above with a link to the CDPH record.
How many complaints have been filed against St. John of God Retirement and Care Center?
From 2023 through October 30, 2026, Cal Health Find lists 87 complaint and facility-reported incident intakes, and CDPH substantiated at least one allegation in 42 of them.
Does Medicare flag St. John of God Retirement and Care Center for abuse?
As of our data date, Medicare Care Compare does not show its abuse icon for St. John of God Retirement and Care Center. The icon is only one signal; read the citations above.
Have there been sexual abuse reports at St. John of God Retirement and Care Center?
Cal Health Find lists no complaint or incident at St. John of God Retirement and Care Center since 2023 that included an allegation CDPH classified as sexual abuse. That reflects only what was reported to the state.
Where can I read reviews and complaints about St. John of God Retirement and 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 St. John of God Retirement and Care Center have?
St. John of God Retirement and Care Center is licensed by CDPH for 156 beds and has a CMS overall rating of 1 out of 5 stars.
Who owns or operates St. John of God Retirement and Care Center?
CDPH lists the licensee as ST. JOHN OF GOD RETIREMENT AND CARE CENTER. CMS does not list a chain for this facility. The CMS ownership file lists St. John of God Retirement and Care Center among the owners or operators. The full list is in the ownership section of this page.
How many nursing hours does St. John of God Retirement and Care Center provide per resident?
Payroll data the facility filed with CMS for April through June 2026 show 4.75 total nursing hours per resident per day, including 0.36 RN hours. The California average is 4.54.
My parent was hurt at St. John of God Retirement and 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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If your loved one was hurt at St. John of God Retirement and 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 St. John of God Retirement and Care Center
| Facility | City | Distance | CMS stars | Class AA/A | Federal G–L |
|---|---|---|---|---|---|
| East Terrace Rehabilitation & Wellness Centre, LP | Los Angeles | 0.1 mi | 1/5 | 2 | 5 |
| Western Convalescent Hospital | Los Angeles | 0.2 mi | 1/5 | 0 | 2 |
| St. Andrews Healthcare | Los Angeles | 0.5 mi | 5/5 | 0 | 0 |
| Sunnyview Care Center | Los Angeles | 0.6 mi | 2/5 | 3 | 2 |
| Sunray Healthcare Center | Los Angeles | 1.0 mi | – | 4 | 11 |
| The Rehabilitation Center on Pico | Los Angeles | 1.0 mi | 2/5 | 4 | 4 |
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
- Cal Health Find – St. John of God Retirement and Care Center
- Medicare Care Compare – St. John of God Retirement and Care Center
- CMS – Payroll-Based Journal Daily Nurse Staffing (2026 Q2)
- CMS – Nursing home Provider Information (staffing, turnover)
- CMS – Nursing home Ownership
- CMS – Nursing home Penalties
- HCAI – Long-Term Care Facility Financial Data
- CDPH – State Enforcement Actions (open data)
- 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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