Monterey Healthcare & Wellness Centre, Lp
MONTEREY HEALTHCARE & WELLNESS CENTRE, LP in ROSEMEAD, CA — inspection on March 27, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview with the Director of Registered Nursing (DON) on 3/27/26 at 11:20 AM, the DON stated she was not aware that Resident 35 was making verbal threats to hit staff.
The DON stated that when a resident expressed verbal threats toward others such as, I want to hit you, staff should create a CIC to communicate the change in the resident's behavior to the rest of the staff, update the care plan to implement interventions, and notify the resident's physician in order to have the resident's medications reevaluated or sent to a GACH for further evaluation.
The DON further explained that a CIC should have been created when Resident 35 first made verbal threats to harm others.
During a review of the facility's Policy and Procedure (P&P) titled, Change in Condition and dated 8/25/22, the P&P indicated the licensed nurse will notify the resident's physician and legal representative when there is: An incident involving the resident A significant change in the residents' mental or psychosocial status
555897 03/27/2026
Monterey Healthcare & Wellness Centre, LP 1267 San Gabriel Blvd Rosemead, CA 91770
During an interview with Activity Staff (AS) 1 on 3/26/26 at 2:04 PM, AS 1 stated that Resident 5
some activities due to his poor vision. AS 1 stated that Resident 5 would not attend group activities that could not accommodate his poor vision.
During an interview with the activities director (AD) on 3/26/26 at 2:30 PM, the AD stated that Resident 5 required one-to-one activity visits because the activity staff noticed that Resident 5 was not actively participating in group activities.
The AD stated Resident 5 presented with low self-esteem and would state he felt like a burden when he could not participate in activities.
During an interview with the DON on 3/27/26 at 12:35 PM and concurrent record review of Resident 5's care plan, the DON stated there should have been a care plan for Resident 5's poor vision so that proper interventions could have been in place and Resident 5 could perform his ADLs.
The DON further stated that if Resident 5 continued to refuse activities, he could isolate and his psychosocial and mental wellbeing could decline.
During a review of the facility's Policy and Procedure (P&P) titled, Person-Centered Care Planning dated 5/22/25, the P&P indicated the facility must develop and implement a comprehensive person-centered care plan for each resident rights and provide services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being.ˆ
555897 03/27/2026
Monterey Healthcare & Wellness Centre, LP 1267 San Gabriel Blvd Rosemead, CA 91770
During the same concurrent interview and record review
not able to contact the physician and he did not come to the facility on 3/10/26 to 3/13/26 to assess
Psychiatric Medical Director because he expected the physician to come in to see the resident on 3/10/26 to 3/13/26. ADON further stated that Resident 54's physical aggression toward Resident 25 on 3/16/2026 could have been avoided if he continued to follow up with Physician 5 and informed the NP or the Psychiatric Medical Director to assess Resident 54 for further recommendations regarding increased hallucinations, delusions, and aggressions towards others.
During an interview on 3/27/2026 at 9:35 AM with LVN 1, LVN 1 stated upon interviewing Resident 54, Resident 54 stated, she made an elbowing motion because she wanted Resident 25 to move out of the way out in the small alcove room by Resident 25's room.
During the same interview on 3/27/2026 at 9:40 AM with LVN 1, LVN stated 1 Resident 54's baseline personality fluctuates between verbal aggression to being withdrawn and shutting people out. LVN 1 stated, there were times Resident 54 did not comply with redirection from the staff members and would ignore everyone around her and will not listen to what we say.
During a review of the facility's policies and procedures (P&P) titled Resident Safety, dated 4/15/2021, the P&P indicated that residents will be evaluated when there is a change of condition to identify circumstances that pose a risk for the safety and welling of the resident.