Live Oak Rehab Center: Dignity Violations Documented - CA
That was the picture federal inspectors found during a complaint inspection at Live Oak Rehab Center, a skilled nursing facility in San Gabriel. The inspection, completed August 19, documented failures to honor the preferences and dignity of at least one resident, identified in records as Resident 1.
Resident 1 told inspectors that night shift staff talked too loudly and wore strong perfume despite being asked not to. "I can smell the night shift staff in the hallway even just standing by my door," she said. The complaints were not new. A Concern Record dated March 14, 2025 had captured her preferences. Social Services Notes spanned April 1 through August 19, 2025.
In more than four months of notes, there was no documentation that the Social Services Director had followed up with Resident 1 about her preferences.
When inspectors interviewed the Social Services Director that afternoon, the explanation was that Resident 1 "brings up personal stories" during visits. The director said she did not document every visit. No follow-up on preferences. No record that anything changed.
The nursing assistant assigned to cover lunch breaks told inspectors she had a simple rule for introductions: if a resident pressed the call light, she would introduce herself. If the resident didn't press the light, she didn't bother. Registered Nurse Supervisor 1 told inspectors that introducing yourself to a resident was part of resident rights, a matter of dignity and respect, and a practical necessity so residents know who to call if their regular staff steps away. "We should always introduce ourselves to the Resident," RNS 1 said.
The care plan record told the same story the social services notes did. RNS 1 reviewed Resident 1's care plans, which ran from March 2024 through August 2025, and confirmed there were no care plans developed to address her preferences. "No care plan means it was not consistently done," RNS 1 said. The supervisor described care plans as the organized mechanism for determining whether the facility is actually managing or solving a resident's problem.
The administrator, interviewed at 3:41 in the afternoon, reviewed the March 14 Concern Record and acknowledged it captured Resident 1's preferences. "We always come and see Resident 1," the administrator said, "but we did not have a documentation every time we visit her to ensure that her preferences are being followed by the staff."
The facility's own written policies said residents shall be treated with dignity and respect at all times, that individual needs and preferences are identified through assessment and honored from admission through the entire stay, and that staff attitudes and behaviors are directed toward helping residents maintain independence, dignity, and well-being in accordance with their wishes. RNS 1 confirmed that when a resident has preferences, the Interdisciplinary Team is supposed to discuss them, and if they meet facility policy, add them to the care plan so staff can implement them. "We have to listen to the resident and accommodate as much as possible," RNS 1 said.
The gap between those words and what Resident 1 experienced was the length of the hallway she could smell perfume from, just standing at her door.
Inspectors classified the violation as causing minimal harm or potential for actual harm, and noted it affected few residents. The complaint inspection covered a single day.
Resident 1 had been asking since at least March. Five months later, she was still asking.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Live Oak Rehab Center from 2025-08-19 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
LIVE OAK REHAB CENTER in SAN GABRIEL, CA was cited for violations during a health inspection on August 19, 2025.
That was the picture federal inspectors found during a complaint inspection at Live Oak Rehab Center, a skilled nursing facility in San Gabriel.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.