SFF Candidate Abuse citation flag

Overview

Address
12831 MACLAY STREET, SYLMAR, CA 91342
Phone
8183614455
Certified beds
141
Avg daily residents
122 (87% of beds filled)
Ownership
For-profit corporation
Provider type
Medicare and Medicaid
Medicare/Medicaid since
1993-12-01
Setting
Urban
2 /5
CMS Overall Rating

CMS 5-Star Ratings

CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.

Overall Rating
Composite of Health Inspection, Staffing, and Quality Measures.
2/5
Health Inspection
Based on the three most recent standard surveys, with more weight on recent results.
1/5
Staffing
Weighted combination of RN and total nurse staffing hours per resident per day, case-mix adjusted.
3/5
Quality Measures
15 resident-level quality measures split between long-stay and short-stay (post-acute) residents.
5/5
Quality Measures breakdown
Long-Stay Quality Measures 5/5
Short-Stay Quality Measures 4/5

Staffing & Workforce

Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.

Role Reported Case-mix expected Adjusted Federal floor
Total nurse
All nursing staff combined: RN + LPN + Aide
4.24 3.86 4.24 ≥ 3.48
Registered Nurse (RN)
Licensed RN hours. Strongest driver of clinical outcomes.
0.36 0.68 0.36 ≥ 0.55 Below floor
Licensed Practical Nurse (LPN)
LPN/LVN hours. Often handles medication administration.
1.25 0.86 1.25
Nurse aide
CNA hours. Bulk of direct resident care — bathing, feeding, mobility.
2.63 2.33 2.63
Licensed (RN + LPN)
Combined licensed nurse coverage.
1.61
Physical therapist
Rehabilitation therapist hours — important for post-acute / rehab admissions.
0.00

Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.

Weekend staffing

Total nurse (weekend)
3.85
hrs / resident / day
RN (weekend)
0.27
hrs / resident / day
Total nurse (adjusted, weekend)
3.85
hrs / resident / day

Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.

Staff turnover

Total nursing staff turnover
47.3%
annual
RN turnover
60.0%
annual
Administrators departed
1
last 12 months

Resident acuity

Nursing Case-Mix Index
1.37
higher acuity than avg
Case-Mix Index Ratio
0.99
facility / state ratio

Health Inspections

CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.

Cycle Date Total defs. Standard Complaint Deficiency score Revisits Total score
Cycle 1 (most recent) 2024-10-11 46 30 16 464 2 696
Cycle 2/3 (prior) 2023-10-06 103 29 79 781 1 781
Total weighted health score
717.3
lower is better

Deficiencies (170)

Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).

1 A/B/C No actual harm — minor
157 D/E/F Actual harm — potential for minor
6 G/H/I Actual harm
6 J/K/L Immediate jeopardy
Tag Description Scope/Severity Survey date Corrected
0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. D 2025-09-15 2025-10-15
0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. D 2025-08-28 2025-09-19
0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. D 2025-08-28 2025-09-19
0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. D 2025-07-09 2025-08-12
0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. D 2025-06-03 2025-06-27
0692 Provide enough food/fluids to maintain a resident's health. D 2025-06-03 2025-06-27
0825 Provide or get specialized rehabilitative services as required for a resident. D 2025-06-03 2025-06-27
0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. D 2025-06-03 2025-06-27
0880 Provide and implement an infection prevention and control program. E 2025-04-28 2025-05-09
0583 Keep residents' personal and medical records private and confidential. E 2025-03-22 2025-04-18
0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. J 2025-03-22 2025-04-18
0610 Respond appropriately to all alleged violations. D 2025-03-22 2025-04-18
0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. D 2025-03-22 2025-04-18
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. J 2025-03-22 2025-04-18
0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. E 2025-03-22 2025-04-18
0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. E 2025-03-22 2025-04-18
0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. D 2025-01-28 2025-02-12
0760 Ensure that residents are free from significant medication errors. D 2025-01-28 2025-02-12
0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. D 2025-01-16 2025-02-04
0554 Allow residents to self-administer drugs if determined clinically appropriate. D 2024-12-24 2025-01-09
0636 Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. D 2024-12-24 2025-01-09
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. D 2024-12-24 2025-01-09
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. D 2024-12-24 2025-01-09
0760 Ensure that residents are free from significant medication errors. D 2024-12-24 2025-01-09
0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. D 2024-12-18 2024-12-30
0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. D 2024-10-31 2024-11-11
0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. D 2024-10-31 2024-11-11
0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. E 2024-10-24 2024-11-08
0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. G 2024-10-24 2024-11-08
0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. E 2024-10-11 2024-11-18
0558 Reasonably accommodate the needs and preferences of each resident. D 2024-10-11 2024-11-18
0561 Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. D 2024-10-11 2024-11-18
0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. E 2024-10-11 2024-11-18
0641 Ensure each resident receives an accurate assessment. D 2024-10-11 2024-11-18
0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted E 2024-10-11 2024-11-18
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. E 2024-10-11 2024-11-18
0658 Ensure services provided by the nursing facility meet professional standards of quality. E 2024-10-11 2024-11-18
0677 Provide care and assistance to perform activities of daily living for any resident who is unable. D 2024-10-11 2024-11-18
0685 Assist a resident in gaining access to vision and hearing services. D 2024-10-11 2024-11-18
0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. D 2024-10-11 2024-11-18
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. E 2024-10-11 2024-11-18
0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. E 2024-10-11 2024-11-18
0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. E 2024-10-11 2024-11-18
0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. D 2024-10-11 2024-11-18
0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. D 2024-10-11 2024-11-18
0760 Ensure that residents are free from significant medication errors. E 2024-10-11 2024-11-18
0802 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. E 2024-10-11 2024-12-06
0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. E 2024-10-11 2024-11-18
0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. E 2024-10-11 2024-11-18
0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. E 2024-10-11 2024-11-18

Showing 50 most recent of 170. See the All Data CSV for the full list.

Penalties (9)

Fines issued
5
last 3 years
Total fines
$297,315
Payment denials
4
Date Type Fine amount
2024-10-11 Fine $17,660
2023-08-23 Fine $28,822
2025-03-22 Fine $51,704
2024-06-07 Fine $86,623
2024-10-11 Fine $112,506
2025-03-22 Payment Denial
2024-10-11 Payment Denial
2024-06-07 Payment Denial
2023-08-23 Payment Denial

Source: CMS Nursing Home Penalties.

Financial Health (FY 2023)

Payer mix (share of resident days)

Medicare 4.3% Medicaid 83.0% Other 12.7%

Operating performance

Operating Margin
-0.8%
Total Margin
-4.3%
Occupancy Rate
87.5%
Cost per Resident Day
$24

Revenue & costs

Net Patient Revenue
$15.9M
Total Costs
$1.1M
Net Income
-$687K

Balance sheet

Total Assets
$4.6M
Total Liabilities
$6.6M
Fund Balance
-$1.7M
Current Ratio
0.74

Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.

Ownership & Corporate Structure

Chain: SERRANO GROUP

Chain ID
659
Facilities in chain
11
Legal business name
MACLAY HEALTHCARE LLC
Chain-average star ratings (for peer context)
Overall
2.3
Health
1.6
Staffing
3.2
QM
4.6

Owner / manager organizations (2)

Organization Role Association
LORY LYNN LLC 5% OR GREATER DIRECT OWNERSHIP INTEREST since 11/01/2015
MACLAY PARTNERS LLC 5% OR GREATER DIRECT OWNERSHIP INTEREST since 11/01/2015

Owner / manager individuals (7)

Name Role Association
JACOBS, DOV 5% OR GREATER DIRECT OWNERSHIP INTEREST since 11/01/2015
LANDA, BENJAMIN 5% OR GREATER DIRECT OWNERSHIP INTEREST since 11/01/2015
FENSTERMAN, HOWARD 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 11/01/2015
TAUB, JUDAH 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 11/01/2015
DONOHOE, MARK OPERATIONAL/MANAGERIAL CONTROL since 11/01/2015
JACOBS, DOV CORPORATE OFFICER since 11/01/2015
LANDA, BENJAMIN CORPORATE OFFICER since 11/01/2015

Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.

Facility Features

CCRC
No
Hospital-based
No
Resident / family council
Both
Sprinkler systems
Yes
Special focus status
SFF Candidate
Abuse citation flag
Yes — last 2 cycles
Methodology & sources

Full methodology →

All Data

Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.

Download CSV

Show 113 rows
Source Metric Value Raw key
Cost Report Cost per Resident Day ($) $24 metrics.cost_per_resident_day
Cost Report Current Ratio 0.74 metrics.current_ratio
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Medicaid Day Share (%) 83.0% metrics.medicaid_day_share
Cost Report Medicare Day Share (%) 4.3% metrics.medicare_day_share
Cost Report Net Income ($) $-687,339 metrics.net_income
Cost Report Net Patient Revenue ($) $15,939,217 metrics.net_patient_revenue
Cost Report Occupancy Rate (%) 87.5% metrics.occupancy_rate
Cost Report Operating Margin (%) -0.8% metrics.operating_margin
Cost Report Total Assets ($) $4,553,209 metrics.total_assets
Cost Report Total Costs ($) $1,076,972 metrics.total_costs
Cost Report Total Fund Balances ($) $-1,741,354 metrics.fund_balance
Cost Report Total Liabilities ($) $6,604,261 metrics.total_liabilities
Cost Report Total Margin (%) -4.3% metrics.total_margin
Provider Information Abuse Icon Y Abuse Icon
Provider Information Adjusted LPN Staffing Hours per Resident per Day 1.24857 Adjusted LPN Staffing Hours per Resident per Day
Provider Information Adjusted Nurse Aide Staffing Hours per Resident per Day 2.63146 Adjusted Nurse Aide Staffing Hours per Resident per Day
Provider Information Adjusted RN Staffing Hours per Resident per Day 0.36001 Adjusted RN Staffing Hours per Resident per Day
Provider Information Adjusted Total Nurse Staffing Hours per Resident per Day 4.24003 Adjusted Total Nurse Staffing Hours per Resident per Day
Provider Information Adjusted Weekend Total Nurse Staffing Hours per Resident per Day 3.84687 Adjusted Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Administrator turnover footnote Administrator turnover footnote
Provider Information Automatic Sprinkler Systems in All Required Areas Yes Automatic Sprinkler Systems in All Required Areas
Provider Information Average Number of Residents per Day 122.1 Average Number of Residents per Day
Provider Information Average Number of Residents per Day Footnote Average Number of Residents per Day Footnote
Provider Information Case-Mix LPN Staffing Hours per Resident per Day 0.85771 Case-Mix LPN Staffing Hours per Resident per Day
Provider Information Case-Mix Nurse Aide Staffing Hours per Resident per Day 2.33106 Case-Mix Nurse Aide Staffing Hours per Resident per Day
Provider Information Case-Mix RN Staffing Hours per Resident per Day 0.67606 Case-Mix RN Staffing Hours per Resident per Day
Provider Information Case-Mix Total Nurse Staffing Hours per Resident per Day 3.86482 Case-Mix Total Nurse Staffing Hours per Resident per Day
Provider Information Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day 3.40644 Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Chain Average Health Inspection Rating 1.6 Chain Average Health Inspection Rating
Provider Information Chain Average Overall 5-star Rating 2.3 Chain Average Overall 5-star Rating
Provider Information Chain Average QM Rating 4.6 Chain Average QM Rating
Provider Information Chain Average Staffing Rating 3.2 Chain Average Staffing Rating
Provider Information Chain ID 659 Chain ID
Provider Information Chain Name SERRANO GROUP Chain Name
Provider Information City/Town SYLMAR City/Town
Provider Information CMS Certification Number (CCN) 555583 CMS Certification Number (CCN)
Provider Information Continuing Care Retirement Community N Continuing Care Retirement Community
Provider Information County/Parish Los Angeles County/Parish
Provider Information Date First Approved to Provide Medicare and Medicaid Services 1993-12-01 Date First Approved to Provide Medicare and Medicaid Services
Provider Information Geocoding Footnote Geocoding Footnote
Provider Information Health Inspection Rating 1 Health Inspection Rating
Provider Information Health Inspection Rating Footnote Health Inspection Rating Footnote
Provider Information Latitude 34.299 Latitude
Provider Information Legal Business Name MACLAY HEALTHCARE LLC Legal Business Name
Provider Information Location 12831 MACLAY STREET,SYLMAR,CA,91342 Location
Provider Information Long-Stay QM Rating 5 Long-Stay QM Rating
Provider Information Long-Stay QM Rating Footnote Long-Stay QM Rating Footnote
Provider Information Longitude -118.42 Longitude
Provider Information Most Recent Health Inspection More Than 2 Years Ago N Most Recent Health Inspection More Than 2 Years Ago
Provider Information Number of administrators who have left the nursing home 1 Number of administrators who have left the nursing home
Provider Information Number of Certified Beds 141 Number of Certified Beds
Provider Information Number of Citations from Infection Control Inspections Number of Citations from Infection Control Inspections
Provider Information Number of Facilities in Chain 11 Number of Facilities in Chain
Provider Information Number of Fines 5 Number of Fines
Provider Information Number of Payment Denials 4 Number of Payment Denials
Provider Information Nursing Case-Mix Index 1.36913 Nursing Case-Mix Index
Provider Information Nursing Case-Mix Index Ratio 0.99382 Nursing Case-Mix Index Ratio
Provider Information Overall Rating 2 Overall Rating
Provider Information Overall Rating Footnote Overall Rating Footnote
Provider Information Ownership Type For profit - Corporation Ownership Type
Provider Information Physical Therapist Staffing Footnote Physical Therapist Staffing Footnote
Provider Information Processing Date 2026-03-01 Processing Date
Provider Information Provider Address 12831 MACLAY STREET Provider Address
Provider Information Provider Changed Ownership in Last 12 Months N Provider Changed Ownership in Last 12 Months
Provider Information Provider Name MACLAY HEALTHCARE CENTER Provider Name
Provider Information Provider Resides in Hospital N Provider Resides in Hospital
Provider Information Provider SSA County Code 200 Provider SSA County Code
Provider Information Provider Type Medicare and Medicaid Provider Type
Provider Information QM Rating 5 QM Rating
Provider Information QM Rating Footnote QM Rating Footnote
Provider Information Rating Cycle 1 Health Deficiency Score 464 Rating Cycle 1 Health Deficiency Score
Provider Information Rating Cycle 1 Health Revisit Score 232 Rating Cycle 1 Health Revisit Score
Provider Information Rating Cycle 1 Number of Complaint Health Deficiencies 16 Rating Cycle 1 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 1 Number of Health Revisits 2 Rating Cycle 1 Number of Health Revisits
Provider Information Rating Cycle 1 Number of Standard Health Deficiencies 30 Rating Cycle 1 Number of Standard Health Deficiencies
Provider Information Rating Cycle 1 Standard Survey Health Date 2024-10-11 Rating Cycle 1 Standard Survey Health Date
Provider Information Rating Cycle 1 Total Health Score 696 Rating Cycle 1 Total Health Score
Provider Information Rating Cycle 1 Total Number of Health Deficiencies 46 Rating Cycle 1 Total Number of Health Deficiencies
Provider Information Rating Cycle 2 Number of Standard Health Deficiencies 29 Rating Cycle 2 Number of Standard Health Deficiencies
Provider Information Rating Cycle 2 Standard Health Survey Date 2023-10-06 Rating Cycle 2 Standard Health Survey Date
Provider Information Rating Cycle 2/3 Health Deficiency Score 781 Rating Cycle 2/3 Health Deficiency Score
Provider Information Rating Cycle 2/3 Health Revisit Score 0 Rating Cycle 2/3 Health Revisit Score
Provider Information Rating Cycle 2/3 Number of Complaint Health Deficiencies 79 Rating Cycle 2/3 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 2/3 Number of Health Revisits 1 Rating Cycle 2/3 Number of Health Revisits
Provider Information Rating Cycle 2/3 Total Health Score 781 Rating Cycle 2/3 Total Health Score
Provider Information Rating Cycle 2/3 Total Number of Health Deficiencies 103 Rating Cycle 2/3 Total Number of Health Deficiencies
Provider Information Registered Nurse hours per resident per day on the weekend 0.27171 Registered Nurse hours per resident per day on the weekend
Provider Information Registered Nurse turnover 60.0 Registered Nurse turnover
Provider Information Registered Nurse turnover footnote Registered Nurse turnover footnote
Provider Information Reported Licensed Staffing Hours per Resident per Day 1.61020 Reported Licensed Staffing Hours per Resident per Day
Provider Information Reported LPN Staffing Hours per Resident per Day 1.24983 Reported LPN Staffing Hours per Resident per Day
Provider Information Reported Nurse Aide Staffing Hours per Resident per Day 2.63411 Reported Nurse Aide Staffing Hours per Resident per Day
Provider Information Reported Physical Therapist Staffing Hours per Resident Per Day 0.00282 Reported Physical Therapist Staffing Hours per Resident Per Day
Provider Information Reported RN Staffing Hours per Resident per Day 0.36037 Reported RN Staffing Hours per Resident per Day
Provider Information Reported Staffing Footnote Reported Staffing Footnote
Provider Information Reported Total Nurse Staffing Hours per Resident per Day 4.24431 Reported Total Nurse Staffing Hours per Resident per Day
Provider Information Short-Stay QM Rating 4 Short-Stay QM Rating
Provider Information Short-Stay QM Rating Footnote Short-Stay QM Rating Footnote
Provider Information Special Focus Status SFF Candidate Special Focus Status
Provider Information Staffing Rating 3 Staffing Rating
Provider Information Staffing Rating Footnote Staffing Rating Footnote
Provider Information State CA State
Provider Information Telephone Number 8183614455 Telephone Number
Provider Information Total Amount of Fines in Dollars 297315.00 Total Amount of Fines in Dollars
Provider Information Total number of nurse staff hours per resident per day on the weekend 3.85075 Total number of nurse staff hours per resident per day on the weekend
Provider Information Total Number of Penalties 9 Total Number of Penalties
Provider Information Total nursing staff turnover 47.3 Total nursing staff turnover
Provider Information Total nursing staff turnover footnote Total nursing staff turnover footnote
Provider Information Total Weighted Health Survey Score 717.250 Total Weighted Health Survey Score
Provider Information Urban Y Urban
Provider Information With a Resident and Family Council Both With a Resident and Family Council
Provider Information ZIP Code 91342 ZIP Code