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MACLAY HEALTHCARE CENTER Inspection Report, Violations & Safety Grade (SYLMAR, California)

12831 MACLAY STREET, SYLMAR, California 91342

Phone: 8183614455

CMS Overall:2/5

Overview & Bed Count

Certified Beds

141

Avg Residents/Day

128

Ownership

For profit - Limited Liability company

Provider Type

Medicare and Medicaid

County

Los Angeles

Sprinkler Systems

Yes

Special Focus

SFF Candidate

Abuse Icon

CMS Star Ratings

Overall2/5

Health1/5

Staffing3/5

Quality5/5

Nurse Staffing Check

Metric	This Facility	California Avg	Difference
RN Hours per Resident per Day	0.39	0.68	-0.29
Total Nurse Hours per Resident per Day	4.00	4.54	-0.54
CMS Staffing Rating	3/5	3.3/5	-
Nursing Staff Turnover	36.4%	36.6%	-

Health Citation History

168 health citations on record

Date	Category	Description	Severity
2026-07-21	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	G – Actual Harm
2026-06-09	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	D – Moderate Harm Potential
2026-06-09	Pharmacy Service Deficiencies	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	D – Moderate Harm Potential
2026-06-09	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential
2026-04-29	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	G – Actual Harm
2026-04-29	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	E – Moderate Harm Potential
2026-04-29	Resident Assessment and Care Planning Deficiencies	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	E – Moderate Harm Potential
2026-04-29	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	D – Moderate Harm Potential
2026-04-14	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	E – Moderate Harm Potential
2026-04-14	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	E – Moderate Harm Potential
2026-04-14	Resident Rights Deficiencies	Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	D – Moderate Harm Potential
2026-04-14	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	D – Moderate Harm Potential
2026-04-14	Pharmacy Service Deficiencies	Ensure each resident’s drug regimen must be free from unnecessary drugs.	D – Moderate Harm Potential
2026-03-03	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Respond appropriately to all alleged violations.	E – Moderate Harm Potential
2026-03-03	Resident Assessment and Care Planning Deficiencies	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	E – Moderate Harm Potential
2026-03-03	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	D – Moderate Harm Potential
2026-01-16	Nutrition and Dietary Deficiencies	Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.	K – Immediate Jeopardy
2026-01-16	Resident Rights Deficiencies	Keep residents' personal and medical records private and confidential.	E – Moderate Harm Potential
2026-01-16	Resident Rights Deficiencies	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 – Moderate Harm Potential
2026-01-16	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.	E – Moderate Harm Potential
2026-01-16	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.	E – Moderate Harm Potential
2026-01-16	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	E – Moderate Harm Potential
2026-01-16	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	E – Moderate Harm Potential
2026-01-16	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	E – Moderate Harm Potential
2026-01-16	Pharmacy Service Deficiencies	Ensure medication error rates are not 5 percent or greater.	E – Moderate Harm Potential
2026-01-16	Pharmacy Service Deficiencies	Ensure that residents are free from significant medication errors.	E – Moderate Harm Potential
2026-01-16	Nutrition and Dietary Deficiencies	Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.	E – Moderate Harm Potential
2026-01-16	Nutrition and Dietary Deficiencies	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 – Moderate Harm Potential
2026-01-16	Nutrition and Dietary Deficiencies	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	E – Moderate Harm Potential
2026-01-16	Nutrition and Dietary Deficiencies	Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.	E – Moderate Harm Potential
2026-01-16	Nutrition and Dietary Deficiencies	Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.	E – Moderate Harm Potential
2026-01-16	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2026-01-16	Resident Assessment and Care Planning Deficiencies	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	E – Moderate Harm Potential
2026-01-16	Administration Deficiencies	Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.	E – Moderate Harm Potential
2026-01-16	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2026-01-16	Infection Control Deficiencies	Implement a program that monitors antibiotic use.	E – Moderate Harm Potential
2026-01-16	Environmental Deficiencies	Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	E – Moderate Harm Potential
2026-01-16	Environmental Deficiencies	Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.	E – Moderate Harm Potential
2026-01-16	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	D – Moderate Harm Potential
2026-01-16	Resident Rights Deficiencies	Reasonably accommodate the needs and preferences of each resident.	D – Moderate Harm Potential
2026-01-16	Resident Rights Deficiencies	Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.	D – Moderate Harm Potential
2026-01-16	Resident Rights Deficiencies	Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	D – Moderate Harm Potential
2026-01-16	Resident Assessment and Care Planning Deficiencies	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	D – Moderate Harm Potential
2026-01-16	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	D – Moderate Harm Potential
2026-01-16	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	D – Moderate Harm Potential
2026-01-16	Quality of Life and Care Deficiencies	Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.	D – Moderate Harm Potential
2026-01-16	Quality of Life and Care Deficiencies	Provide safe, appropriate pain management for a resident who requires such services.	D – Moderate Harm Potential
2026-01-16	Quality of Life and Care Deficiencies	Provide safe, appropriate dialysis care/services for a resident who requires such services.	D – Moderate Harm Potential
2026-01-16	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	D – Moderate Harm Potential
2026-01-16	Pharmacy Service Deficiencies	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	D – Moderate Harm Potential

Showing 50 of 168 citations.

Fire Safety Citation History

19 fire safety citations on record

Date	Category	Description	Severity
2026-08-13	Egress Deficiencies	Keep aisles, corridors, and exits free of obstruction in case of emergency.	D – Moderate Harm Potential
2026-01-16	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	F – Moderate Harm Potential
2026-01-16	Services Deficiencies	Have properly installed electrical wiring and gas equipment.	F – Moderate Harm Potential
2026-01-16	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	F – Moderate Harm Potential
2026-01-16	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	E – Moderate Harm Potential
2026-01-16	Smoke Deficiencies	Properly select, install, inspect, or maintain portable fire extinguishes.	E – Moderate Harm Potential
2026-01-16	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure proper usage of power strips and extension cords.	E – Moderate Harm Potential
2026-01-16	Smoke Deficiencies	Provide properly protected cooking facilities.	D – Moderate Harm Potential
2026-01-16	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	D – Moderate Harm Potential
2026-01-16	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.	D – Moderate Harm Potential
2024-10-11	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	E – Moderate Harm Potential
2024-10-11	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	E – Moderate Harm Potential
2024-10-11	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	D – Moderate Harm Potential
2024-10-11	Services Deficiencies	Have properly installed electrical wiring and gas equipment.	D – Moderate Harm Potential
2024-10-11	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure proper usage of power strips and extension cords.	D – Moderate Harm Potential
2024-10-11	Emergency Preparedness Deficiencies	Provide emergency officials' contact information.	C – Minimal Harm Potential
2023-10-06	Egress Deficiencies	Keep aisles, corridors, and exits free of obstruction in case of emergency.	E – Moderate Harm Potential
2023-10-06	Egress Deficiencies	Have properly located and lighted "Exit" signs.	D – Moderate Harm Potential
2023-10-06	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	D – Moderate Harm Potential

Total Penalties & Fines

$349,023

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2026-07-21	Fine	$22,895	-
2026-04-29	Fine	$12,747	-
2026-01-16	Fine	$44,450	-
2026-01-16	Payment Denial	-	38 days starting 2026-02-17
2025-03-22	Fine	$52,142	-
2025-03-22	Payment Denial	-	20 days starting 2025-04-19
2024-10-11	Fine	$17,660	-
2024-10-11	Fine	$112,506	-
2024-10-11	Payment Denial	-	14 days starting 2024-11-22
2024-06-07	Fine	$86,623	-
2024-06-07	Payment Denial	-	6 days starting 2024-07-09

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Need Help Finding Safe Care?

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Find Safe, Vetted Facilities Near SYLMAR
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)

Advisor service is free for families. We may receive referral compensation.