Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
THE PAVILION AT SUNNY HILLS
FULLERTON, CA · 300 certified beds · Last Life Safety survey April 28, 2025
CMS Certification Number 555733 · first certified January 1999
Ownership
Operated by PURSUE HEALTH · For profit - Partnership
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within CA
18 citations — more than 43% of the 1,165 certified nursing homes in CA. Compared within CA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 3 citations; the earlier surveys in the window averaged 7.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: May 2026 to October 2026. This facility’s last Life Safety survey was April 2025. Facilities in CA are typically surveyed 12–18 months after the last one (median 14), measured over 1,766 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 18 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
11 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 18 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0908 Keep all essential equipment working safely.
- F-0909 Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
How that compares
Compared with the median facility in CA, and nationally. Surveyors differ markedly between states, so the CA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 18 |
| Median facility in CA | 19 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 16, 2021 | 8 |
| December 7, 2023 | 7 |
| April 28, 2025 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0923 | Have proper medical gas storage and administration areas. | 3 | 2025-04-28 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2023-12-07 |
| K-0161 | Use approved construction type or materials. | 2 | 2025-04-28 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 2 | 2023-12-07 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1 | 2023-12-07 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1 | 2025-04-28 |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | 1 | 2021-11-16 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2021-11-16 |
What the citations cover
- Smoke Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Services Deficiencies 3
- Emergency Preparedness Deficiencies 2
- Other 5
| Category | Citations |
|---|---|
| Smoke Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Services Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 2 |
| Construction Deficiencies | 2 |
| Miscellaneous Deficiencies | 2 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 28, 2025 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (May 7, 2025) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (May 7, 2025) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (May 7, 2025) |
December 7, 2023 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (January 8, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (January 8, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (January 8, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (January 8, 2024) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (January 8, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (January 8, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (January 8, 2024) |
November 16, 2021 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (December 17, 2021) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (December 17, 2021) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (December 17, 2021) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 17, 2021) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (December 17, 2021) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (December 17, 2021) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (December 17, 2021) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (December 17, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.