Mother Theresa Hospice, Inc.
A hospice in Burbank, California 91505
847 North Hollywood Way, Ste 203b, Burbank, California 91505. (818) 566-9710.
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The short answer
Record last released by CMS on Oct 23, 2026. We couldn’t read Centers for Medicare & Medicaid Services’ list since Oct 27, 2026: qcor.cms.gov now refuses our reader. This record is as of then.
- 21 deficiencies cited in the last three years
- Not rated family caregiver rating
- 10of 10 CMS’s Hospice Care Index
Each figure’s source sits beside it, in its section below.
What these words mean2
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
21 deficiencies cited in the last three years
The middle of the 154 hospices serving ZIP code 91505 had 5.
The last inspection on record was on Aug 20, 2026: a follow-up inspection by The Joint Commission.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
When those deficiencies happened
21 deficiencies in 2 months of the last 36. Last cited Jul 2026. Most serious: Standard-level. The last 3 years, to Oct 27, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Jul 10, 2026: reaccreditation inspection by The Joint Commission18 deficiencies
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Plan Based on All Hazards Risk Assessment (42 CFR 418.113(a)(1))
The inspectors’ words, 146 words
“Observed in Emergency Management Session. The organization failed to conduct and document a Hazard Vulnerability Assessment (HVA) for calendar years 2024, 2025,2026. During document review and interview with Administrator, no evidence was provided demonstrating an annual HVA had been completed to identify and prioritize potential hazards and risks that could affect the organization’s ability to provide safe patient care and maintain operations during emergencies. This finding was discussed and confirmed by the DPCS. Observed in Emergency Management Session. The organization failed to conduct a Hazard Vulnerability Analysis (HVA) utilizing an all-hazards approach. There was no evidence that the organization systematically identified and prioritized potential emergency events, including natural, technological, human-caused, and infectious disease hazards, to assess risks and vulnerabilities. The Administrator was unable to provide evidence that identified hazards had been prioritized based on likelihood and impact. This finding was discussed and validated by the Administrator/DPCS.”
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Plan Based on All Hazards Risk Assessment (42 CFR 418.113(a)(2))
The inspectors’ words, 108 words
“Observed in Emergency Management Session. .The organization failed to identify and mitigate risks and hazards that could affect patient care, staff safety, and continuity of operations. The Administrator was unable to provide evidence that mitigation strategies had been developed, implemented, or monitored for effectiveness. This finding was discussed and confirmed with the Administrator/DPCS. Observed in Emergency Management Session. The organization failed to evaluate and prioritize identified hazards and threats through a Hazard Vulnerability Analysis (HVA) . There was no documented process was in place to evaluate identified hazards and threats as well as prioritized based on risk assessment findings. This finding was discussed and validated by the Administrator/DPCS”
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Exercise of rights/respect for proprty/person (42 CFR 418.52(b)(1)(i))
“Observed in Record Review. In 1 of 2 live discharge records with extended prognosis, patient was informed in advance about the expected outcomes of care and services. For example, in RRDC#11 the patient was discharged from hospice services due to patient no longer terminally ill. The Notification of Medicare Non-Coverage (NOMNC) was provided however, it was issued on the same day the patient was discharged. This finding was discussed and validated by the Administrator/DPCS.”
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Rights of the patient (42 CFR 418.52(c)(1))
“Observed in Patient Home. In 1 of 2 home visits conducted, it was noted the organization failed to assess and manage pain. For example, during home visit of HOSRRHV#1, the patient reported experiencing pain. However, the clinician did not complete a comprehensive pain assessment, including description of pain, severity/intensity, frequency, and current pain management interventions or medication taken, as required by the agency policy (Pain Assessment). The clinician just asked patient if she had pain. This finding was discussed and confirmed by the Administrator/DPCS.”
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Initial & comprehensive assessment of patient (42 CFR 418.54)
“Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure that assessment includes all areas of hospice related to the palliation and management of the terminal illness and related conditions. In HOSRRDC#5, several LVN skilled visit notes were incomplete. Specifically, the body systems assessment section was left blank, resulting in the absence of documented-clinical assessment findings for the patient’s condition at the time of the visit. This finding was discussed and confirmed by the Administrator/DPCS.”
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Content of plan of care (42 CFR 418.56(c)(4))
The inspectors’ words, 272 words
“Observed in Record Review. In 3 of 12 patient records reviewed, it was noted the organization failed to ensure that the plan of care includes all services needed for the palliation and management of the terminal illness and related conditions, including the treatment or interventions to meet the patient’s needs. For example in HOSRRDC#3, HOSRRDC#6 , in review of the patient’s initial comprehensive assessment revealed that the patient was identified as being at high risk for falls, and the assessing clinician documented that a referral to Physical Therapy (PT) would be made for further evaluation. However, subsequent review of the interdisciplinary group (IDG) meeting documentation indicated that the Hospice RN reported the patient had become progressively weaker since admission. Despite this change in the patient’s condition and the increased fall risk, the IDG documentation did not include discussion of a PT evaluation or any alternative interventions to address the patient’s functional decline. Additionally, no updated plan of care or documented interventions were identified to mitigate the patient’s increased fall risk. Also noted in HOSRRDC#6, SN reported that the patient was experiencing skin itching and discomfort (Pruritus), however, there was no documented update to the individualized plan of care reflecting interventions, monitoring, or follow up for the patient’s pruritus. In HOSRRHV#2, review of the clinical record identified a physician’s order for home oxygen therapy that stated, oxygen 2-5 LPM via NC PRN for shortness of breath. The order did not include specific clinical parameters or guidance indicating when the oxygen flow rate should be adjusted within the prescribed range of 2-5 liters per minute. This finding was discussed and validated by the Administrator/DPCS.”
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Program scope (42 CFR 418.58(a)(1))
“Observed in Data Session. The hospice surveyor noted the QAPI program did not demonstrate improvement in its palliative outcomes and hospice services as evidenced by the HCO was not able to provide documentation at the time of survey.”
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Program data (42 CFR 418.58(b)(1))
“Observed in Data Tracer. The surveyor noted the hospice did not use patient care indicator data in the design of its quality assessment and improvement program as evidenced by the HCO was not able to produce this documentation at the time of survey.”
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Program data (42 CFR 418.58(b)(2)(ii))
“Observed in Leadership Session. The surveyor noted the HCO did not use the results of data analysis to identify improvement opportunities as evidenced by lack of PI project for the last 3 years. 2024, 2025, 2026. This finding was discussed and validated by the Administrator/DPCS.”
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Program activities (42 CFR 418.58(c)(1)(i))
“Observed in Leadership Session. The surveyor noted the hospice did not select performance improvement activities that affect patient safety, palliative outcomes or that were high-volume, high-risk, problem-prone areas as evidenced by the HCO was not able to produce this documentation at the time of survey.”
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Program activities (42 CFR 418.58(c)(3))
“Observed in Data Session. The surveyor noted the HCO did not act on improvement opportunities as evidenced by lack of PI project for 2024, 2025, 2026. This finding was discussed and validated by the Administrator/DPCS.”
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Performance improvement projects (42 CFR 418.58(d)(2))
“Observed in Data Tracer. The surveyor noted the organization failed to document what performance improvement projects were being conducted, the reasons for conducting and the measurable progress achieved as evidenced by the HCO was not able to produce this documentation at the time of survey. There was documentation of aggregated data and analysis yet no further performance improvement plans and no documentation of performance improvement from 2024, 2025, 2026.”
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Hospice aide assignments and duties (42 CFR 418.76(g)(1))
The inspectors’ words, 196 words
“Observed in Record Review. In 4 of 5 patient records with hospice aide services, it was noted the organization had failed to ensure that the written patient care instructions for a hospice aide must be prepared by a registered nurse who is responsible for the supervision of a hospice aide. For example, in record of HOSRRHV#1, review of the hospice Aide Care Plan/Assignment revealed that the patient was receiving home oxygen therapy; however, the aide care plan did not include specific instructions or guidance for the hospice aide regarding oxygen safety and precautions during the provision of personal care. In HOSRRHV#2, the aide care plan did not include specific instructions or guidance for the hospice aide regarding oxygen safety and precautions and safety instructions on bleeding precautions related to anti-coagulant therapy (Eliquis). HOSRRDC#5, the aide care plan did not include specific instructions or guidance for the hospice aide regarding oxygen safety and precautions and safety instructions on bleeding precautions related to anti-coagulant therapy (Warfarin). HOSRRDC#11, the aide care plan did not include specific instructions or guidance for the hospice aide on bleeding precautions related to anti-platelet therapy (Aspiri)This finding was discussed and validated by the Administrator/DPCS.”
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Governing body and administrator (42 CFR 418.100(b))
“Observed in HR File Review. In 1 of 10 HR files reviewed, review of personnel records HR#4, revealed that the agency failed to perform annual Office of Inspector General (OIG) exclusion checks in accordance with its own policy. 2024, 2025, 2026 were not done. This finding was discussed and validated by the Adm/DPCS.”
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Authentication (42 CFR 418.104(b))
The inspectors’ words, 119 words
“Observed in Record Review. In 12 of 12 patient records reviewed, it was noted the organization failed to ensure that all entries in the patient record are legible, clear, complete, and appropriately authenticated and dated. For example in review of HOSRRHV#1, HOSRRHV#2, HOSRRNHV#4, HOSRRNHV#5, HOSRRNHV#6, HOSRRNHV#7, HOSRRNHV#8, HOSRRNHV#9, HOSRRNHV#10,HOSRRNHV#11, and HOSRRNHV#12, in review of the paper-document Home Oxygen Safety Assessment and Home Environment Safety Assessment forms revealed that the documents contained a completed assessment information; however , the forms were not fully authenticated. The assessments did not consistently include the clinician’s professional credentials with the signature, making it difficult to identify the author responsible for performing and documenting the assessment. This finding was discussed and validated by the Administrator/DPCS.”
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Discharge or transfer of care (42 CFR 418.104(e)(3)(ii))
“Observed in Record Review. In 10 of 10 live discharged records, during clinical record review of HOSRRDC#4,HOSRRDC#5, HOSRRDC#6,HOSRRDC#7,HOSRRDC#8,HOSRRDC#9,HOSRRDC#10,HOSRRDC#11,HOSRRDC#12 it was determined that the agency failed to transmit essential clinical documents to the receiving provider at the time of patient discharge. The discharge information did not include the current plan of care necessary to support continuity of care following discharge. This finding was discussed and validated by the DPCS.”
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Discharge or transfer of care (42 CFR 418.104(e)(3)(iii))
“Observed in Record Review. In 10 of 10 live discharged records, during clinical record review of HOSRRDC#4,HOSRRDC#5, HOSRRDC#6,HOSRRDC#7,HOSRRDC#8,HOSRRDC#9,HOSRRDC#10,HOSRRDC#11,HOSRRDC#12 it was determined that the agency failed to transmit essential clinical documents to the receiving provider at the time of patient discharge. The discharge information did not include the current applicable physician orders, and other pertinent clinical documentation necessary to support continuity of care following discharge. This finding was discussed and validated by the DPCS.”
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Discharge or transfer of care (42 CFR 418.104(e)(3)(iv))
“Observed in Record Review. In 10 of 10 live discharge records, during clinical record review of HOSRRDC#4,HOSRRDC#5, HOSRRDC#6,HOSRRDC#7,HOSRRDC#8,HOSRRDC#9,HOSRRDC#10,HOSRRDC#11,HOSRRDC#12 it was determined that the agency failed to transmit essential clinical documents to the receiving provider at the time of patient discharge. The discharge information did not include the current medication list, current plan of care, applicable physician orders, and other pertinent clinical documentation necessary to support continuity of care following discharge. This finding was discussed and validated by the DPCS.”
Jan 26, 2024: follow-up inspection by The Joint Commission3 deficiencies
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Patient outcome measures (42 CFR 418.54(e)(2))
“Observed in Record Review. In 1 of 5 patient records reviewed, the organization failed to maintain a complete and accurate record. During record review for RRNHV#2 there was a physicians order on the medication profile for Oxycodone 10mg 1 tab every 8 hours for severe pain, however on review of the RN visit and IDG documentation it was documented that the patient was taking Oxycodone 10mg 1 tab every 6 hours PRN for pain. This observation was reviewed with the DPCS.”
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Content of plan of care (42 CFR 418.56(c))
The inspectors’ words, 210 words
“Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to plan the patient’s care with goals that were measurable and time-bound. On review of RRNHV#2 it was noted that the goals established were consistently noted to have achieve by dates of the end of the benefit period (BP) even for short term goals and some were not measurable. An example was Caregiver will verbalize/express understanding of treatment order for supplementary oxygen use and safety by (end of BP in March) Patient`s episodes of shortness of breath will be managed/controlled with supplementary oxygen as ordered by (end of BP in March) . In RRNHV#5 there were also goals that remained the same IDG to IDG with achieve by dates of the end of benefit period such as Caregiver will verbalize understanding on fall prevention and safety precautions by (end of BP in Feb) -Caregiver will verbalize understanding regarding Oxygen use and safety by (end of BP in Feb) and Patient will have adequate food and fluids consumption of 60% or more to maintain nutritional support by (end of BP in Feb) then re assess on the next IDT These goals were established on admission nearly six months ago. This observation was reviewed with the DPCS. 
”
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Performance improvement projects (42 CFR 418.58(d)(2))
“Observed in Data Session. the organization failed to document what performance improvement projects were being conducted, the reasons for the projects, and the measurable progress achieved on the projects. During discussion in the data session the DPCS was able to describe areas where the organization was working to improve performance and data collected for the quarterly QAPI meeting, yet was unable to show documentation of specific performance improvement projects being conducted by the organization. This observation was reviewed with the DPCS.”
All 3 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Aug 20, 2026 | Follow-up inspection by The Joint Commission | No deficiencies cited |
| Jul 10, 2026 | Reaccreditation inspection by The Joint Commission | 18 deficiencies cited |
| Jan 26, 2024 | Follow-up inspection by The Joint Commission | 3 deficiencies cited |
Is it certified?
- Medicare-certified hospice since Sep 9, 2014.
- Ownership: for-profit.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency or CMS’s most serious finding: the place’s failure to meet a rule caused, or was likely to cause, serious injury, harm, impairment or death to someone in its care. Source: CMS; 42 CFR 489.3. on record in the last three years.
CMS, Hospice General Information. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Has anything been proven against it?
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- 0 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Who does the caring?
- From Medicare claims (Jan 1, 2023 to Dec 31, 2024): 11.6 nurse care minutes per routine home care day, 19.6% of skilled nursing minutes at weekends and a visit near death for 77.3% of patients who died.
- Where its patients were cared for (Jan 1, 2024 to Dec 31, 2024): 100% at home.
CMS, Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | This provider |
|---|---|
| Nurse care minutes per routine home care day | 11.6 min |
| Skilled nursing minutes at weekends | 19.6% |
| Visits near death | 77.3% of patients who died |
Who owns it?
- 9 owners or officers are people: Kristina Kasabyan (owns 5% or more directly, 75%); Kristina Kasabyan (corporate officer, 75%); Kristina Kasabyan (corporate director, 75%); Kristina Kasabyan (runs it (operational or managerial control), 75%); Juvy J Lahom (owns 5% or more directly, 25%); Juvy J Lahom (corporate officer, 25%); Juvy J Lahom (corporate director, 25%); Juvy J Lahom (managing employee (on the payroll), 25%); Juvy J Lahom (runs it (operational or managerial control), 25%).
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospice All Owners and Hospice Enrollments. Released Sep 29, 2026. Updated quarterly.
What do families say?
- CMS gives no family caregiver survey rating: “The number of cases is too small to report Star Ratings.”
- CMS’s Hospice Care Index: 10 of 10 (Jan 1, 2023 to Dec 31, 2024).
- 83.33% of patients were assessed on all seven of CMS’s measures at the start of care (Oct 1, 2024 to Sep 30, 2025).
CMS, CAHPS Hospice Survey and Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Family caregiver survey ratingCMS star rating from its survey of patients’ family caregivers, 1 to 5 | Not rated |
| Hospice Care IndexCMS’s Hospice Care Index, 0 to 10 (higher is better): a point for each of ten measures from Medicare claims on which the hospice meets CMS’s threshold | 10 of 10 |
How does it compare nearby?
- Of the 154 hospices CMS’s data show serving patients in ZIP code 91505, where this hospice’s office is, the middle number of deficiencies cited in the last three years was 5; this one had 21.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
| Place | Deficiencies, 3 years |
|---|---|
| Compassionate Hospice Care, Inc. | 4 |
| Americare Hospice, Inc. | Not given |
| Mother Theresa Hospice, Inc. This hospice | 21 |
| A & E Hospice Care, Inc. | Not given |
| Angel’s Hand Hospice Care, Inc. | 5 |
| Blue Pacific Hospice Care, Inc. | 0 |
| Illuminate Hospice Care, Inc. | 9 |
| On Time Hospice Care Inc. | Not given |
| First Choice Hospice Health Care Inc. | Not given |
| Liem Hospice | 6 |
| Ametrine Hospice | 8 |
| Regal Hospice and Palliative Care Inc. | 12 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- CMS ended its Special Focus Program for hospices with serious problems on Feb 14, 2025, so no hospice is marked as one.
- Hospice quality measures have a gap from October 2025: CMS replaced its patient assessment then, and public results from the new one (HOPE) are expected around November 2027.
Sources
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Centers for Medicare & Medicaid Services, Hospice General Information (yc9t-dgbk).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Provider Data (252m-zfp9).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, CAHPS Hospice Survey (gxki-hrr8).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR hospice inspection reports (Hospice Survey Reports - Oct 2021 through Sep 2026.xlsx).
Released Oct 23, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice All Owners (e983965e-1603-4cb8-82b5-c40090e380d1).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Enrollments (25704213-e833-4b8b-9dbc-58dd17149209).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice ZIP Data (95rg-2usp).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Oct 27, 2026.
From the hospice
The public record above comes first. Anything the hospice adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospice will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospice”, and paying will never change a finding, a rating or the order of results.