LOS ANGELES, CA — California's Department of Public Health has initiated license suspension proceedings against seven Los Angeles County nursing home operators after each facility received at least two AA-level citations — the state's most severe violation category, indicating failures that substantially contributed to resident deaths — within a two-year period, according to reporting by Corinne Purtill of the Los Angeles Times.
The facilities targeted in the May 2025 enforcement action include Ararat Nursing Facility in Mission Hills, Antelope Valley Care Center in Lancaster, Brier Oak on Sunset in Hollywood, Golden Haven Care Center in Glendale, Kei-Ai Los Angeles Healthcare Center in Lincoln Park, Santa Anita Convalescent Hospital in Temple City, and Seacrest Post-Acute Care Center in San Pedro. Tony Chicotel of California Advocates for Nursing Home Reform described the coordinated action as unprecedented in the state's regulatory history, according to the Los Angeles Times.
The cases involve disturbing patterns of negligence. At Golden Haven Care Center, staff reportedly withheld insulin from a diabetic resident and failed to monitor the patient's blood sugar levels for 61 consecutive days, ultimately leading to hospitalization and death in April 2024, as reported by the Los Angeles Times. At Ararat Nursing Facility, the state cited the operator over lapses connected to the deaths of two residents who died less than three months apart, according to Xinhua News Agency. Attorney Mark E. Reagan, who represents Ararat, told reporters the facility intends to appeal.
The case of Brier Oak on Sunset illustrates both the severity of the crisis and the complexity of regulatory enforcement. The state ultimately dropped its suspension effort against Brier Oak after determining that two patient deaths — one in May 2022 and another in August 2024 — occurred 26 months apart, narrowly exceeding the 24-month statutory window required for suspension, as reported by the Los Angeles Times. The initial confusion arose because the citations themselves had been issued only 22 months apart. The May 2022 death involved a patient who died roughly 50 hours after admission when staff failed to administer critical medications for two days, according to the Times. A court later awarded the family $1.29 million in arbitration, with Judge Terry A. Green finding the facility was "severely understaffed."
However, Brier Oak's troubles continued. As reported by Aaron Schrank of LAist in December 2025, the facility received a third AA citation on November 26, 2025, after a 92-year-old resident died on September 27, 2025. Staff reportedly continued administering blood thinner heparin injections for more than 40 hours despite signs of internal bleeding, resulting in a $120,000 fine. Brier Oak is owned by publicly traded Genesis Healthcare, which filed for Chapter 11 bankruptcy in July 2025, according to LAist. Chicotel told LAist: "There were red flags, and a lot of these red flags existed prior to the death of this poor resident."
The enforcement action also comes amid broader scrutiny of California's nursing home oversight system. A November 2025 investigation by Jocelyn Wiener of CalMatters examined systemic failures in how the state licenses and monitors nursing home operators, raising questions about whether regulators have acted quickly enough when warning signs emerged.
CMS Inspection History
Federal inspection data underscores the depth of quality concerns across Los Angeles County nursing facilities. While the state's enforcement action targets seven specific operators, CMS records reveal widespread compliance challenges in the region.
Crenshaw Nursing Home in Los Angeles, a 55-bed for-profit facility operating as a limited liability company, holds CMS's lowest possible overall rating of 1 out of 5 stars, with an equally poor health inspection rating of 1 out of 5 stars. The facility has accumulated 110 total deficiencies across 38 inspections on federal record, according to CMS data — an average of nearly three deficiencies per inspection.
The facility's most recent CMS inspection, conducted on August 12, 2025, cited the home for failing to honor residents' rights to be treated with respect and dignity and to retain personal possessions, as well as for failing to timely report suspected abuse, neglect, or theft and share investigation results with proper authorities. Both citations carried a severity level of D, indicating the potential for more than minimal harm.
An earlier inspection on March 21, 2025, found deficiencies in developing complete care plans that meet all resident needs with measurable timetables and actions, in ensuring services meet professional standards of quality, and in providing appropriate pressure ulcer care and preventing new ulcers from developing — the latter citation elevated to a severity level of E, indicating actual harm to residents. Federal regulations require nursing facilities to develop comprehensive care plans for each resident and maintain staffing sufficient to meet professional standards. Facilities that repeatedly fail to meet these benchmarks face escalating federal enforcement actions.
While Crenshaw Nursing Home's staffing and quality measure ratings stand at 3 out of 5 stars — suggesting moderate performance in those specific metrics — the persistent pattern of health inspection deficiencies signals ongoing challenges in day-to-day care delivery that families should carefully evaluate.
Ownership & Operations
The state's enforcement action highlights the role of for-profit ownership structures in nursing home quality. All seven targeted facilities operate under for-profit models, a pattern consistent with national research showing that for-profit nursing homes tend to receive more deficiency citations than their nonprofit counterparts.
California law requires that nursing home operators cited with two or more AA violations within a 24-month period face potential license suspension — a standard that the CDPH is now enforcing against six remaining facilities after the Brier Oak case was withdrawn on a technicality. The proceedings represent a significant test of the state's willingness and capacity to hold negligent operators accountable, particularly as some facilities have indicated they plan to contest the actions through appeals.
Resources for Families
Families with loved ones in California nursing homes who have concerns about the quality of care should know that multiple resources are available. The California Long-Term Care Ombudsman program investigates complaints and advocates for residents and can be reached at 1-800-231-4024. The National Long-Term Care Ombudsman Resource Center also operates a hotline at 1-800-677-1116 and maintains a directory of state and local ombudsman programs at [ltcombudsman.org](https://ltcombudsman.org).
Families have the right to file complaints with the California Department of Public Health directly, request copies of a facility's most recent inspection reports, and review a nursing home's full deficiency history through CMS's Care Compare tool at medicare.gov. Federal law entitles residents and their families to access these records, and nursing homes are required to post their most recent inspection results in a location accessible to all visitors.
If you suspect abuse, neglect, or immediate danger to a nursing home resident, contact local law enforcement and Adult Protective Services in addition to the ombudsman program. Documentation — including photographs, medical records, and written accounts of incidents — can be critical to supporting a complaint.
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