Uni Hospice, Inc.
A hospice in Glendale, California 91204
434 W Colorado St Suite 203, Glendale, California 91204. (747) 307-3195.
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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.
- 32 deficiencies cited in the last three years
- Not rated family caregiver rating
- Not available CMS’s Hospice Care Index
Each figure’s source sits beside it, in its section below.
What these words mean3
- 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.
- Condition-level deficiency
- 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.
What did inspectors find?
32 deficiencies cited in the last three years
The middle of the 151 hospices serving ZIP code 91204 had 4.
The last inspection on record was on Feb 17, 2026: a follow-up inspection by The Joint Commission.
3 deficiencies at condition level, the more serious of CMS’s two levels
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
32 deficiencies in 2 months of the last 36. Last cited Feb 2026. Most serious: Condition-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.
Feb 17, 2026: follow-up inspection by The Joint Commission4 deficiencies
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Content of plan of care (42 CFR 418.56(c))
The inspectors’ words, 144 words
“Observed in Record Review. In 3 out of 4 patient records reviewed, the organization failed to plan the patient’s care with measurable and time specific goals. On RRNHV #1, it was noted that goals were not measurable and specific with examples of “patient will maintain blood pressure within target range as prescribed by MD” and “patient will maintain therapeutic anticoagulation” On RRNHV #3, goals not measurable and specific with example of “patient will maintain stable blood pressure within the target” and there is no ordered target. On RRDC #1, it was noted that goals had not been developed to be measurable and specific prior to discharge with examples of “patient’s hypertension will be controlled by medication”, “maintain adequate nutritional intake”, and no timeframe for “Patient to apply for the Friendly Visitor Program for increased socialization”. This was discussed and reviewed with the DCPS designee.”
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Content of plan of care (42 CFR 418.56(c)(3))
The inspectors’ words, 163 words
“Observed in Record Review. In 3 of 4 patient records reviewed, the organization failed to ensure the plan of care was updated based on the patient’s reassessment and progress toward goals. In RRNHV #2 the plan of care had not been updated to reflect the current assessment, achieving goals that had been achieved. For example, every teaching goals were unaltered for IDG to IDG since admission 2 months ago with no change or update to their progress. On RRNHV #3 the plan of care has not been updated to reflect goals that have been achieved based on assessment, patient has goal for altered skin to be healed but the recent assessments don’t document that the patient has any altered skin. On RRDC #1, the plans of care were reviewed prior to discharge, and the Plan of care had not been updated to reflect achieved goals with teaching goals present throughout the entire length of stay. This finding was reviewed with the DCPS designee.”
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Content of plan of care (42 CFR 418.56(c)(4))
“Observed in Record Review. In 1 of 3 active patient records reviewed, the hospice nurse surveyor noted medication orders were not clear and accurate. On RRNHV # 1 the physician’s orders in the plan of care documented MiraLAX PRN for constipation and Colace PRN for constipation; however, there was no indication how to handle the duplicate PRN therapy. This was discussed with the DCPS designee.”
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Coordination of services (42 CFR 418.56(e)(2))
“Observed in Record Review. On 1 of 3 bereavement records reviewed, the organization did not follow the plan of care. On RRBR #2, the bereavement plan of care called for a mailing to be sent at one month but there is no documentation to indicate that letter was sent. This finding was reviewed with the DCPS designee.”
Nov 6, 2025: initial inspection by The Joint Commission28 deficiencies
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Quality assessment & performance improvement (42 CFR 418.58)
The inspectors’ words, 104 words
“Observed in Data Session. On review of the QAPI program, the hospice had no documentation of ongoing, hospice wide, date driven quality assessment process improvement program for the last three years. In discussions with the organization, they have recognized the issue and have done an assessment of the organization but have not had the meeting yet to set up the program. This was reviewed by the DCPS designee. Observed in Data Session. On review of the QAPI program, the hospice program did not have a quality assessment and improvement program in place for the last three years. This was reviewed by the DCPS designee.”
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Governing body and administrator (42 CFR 418.100(b))
“Observed in Tracer Activities. The organization failed to implement policies and procedures. During tracer activities the Hospice Nurse Surveyor observed the organizational leaders did not implement policies and procedures which results in non-compliance with 418.58, 418.116 and 418.100. This finding was reviewed with DCPS designee.”
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Federal, state, local laws & regulations (42 CFR 418.116)
The inspectors’ words, 132 words
“Observed in Record Review. In 1 out of 2 patient records reviewed where patient death occurred, the organization failed to ensure that the patient’s pronouncement follow agency policy and California statute. Agency Death Policy (4-069) states that the attending physician will pronounce death. On RRBR #2, the LVN note stated SN declared patient time of death at 11:15 am, there was no documentation that the LVN contacted the physician to pronounce death. This is not in compliance with agency policy, or California law and regulations. This was discussed and verified with the DPCS designee. Observed in Leadership Session. On review of leadership, the organization had a 49% ownership change this year and the organization did not notify California Department of Health of this change. This finding has been reviewed with agency leadership.”
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EP Testing Requirements (42 CFR 418.113(d)(2))
“Observed in Emergency Management Session. The organization had not conducted exercises to test the emergency plan at least annually. On review of the organizations Emergency Plan they did not have documentation of a drill for 2024. This was reviewed with the DCPS designee.”
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Exercise of rights/respect for proprty/person (42 CFR 418.52(b)(1)(i))
“Observed in Record Review. In 3 of 3 discharge records reviewed, the patient discharged from service without the completion of a Notice of Medicare Non Coverage (NOMNC) completed prior to discharging patient from service. On review of RRDC #1, RRDC #2 and RRDC #3, the agency did not have record that the NOMNC was completed prior to discharging the patient from service. This finding was reviewed and discussed with DCPS designee.”
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Content of plan of care (42 CFR 418.56(c))
The inspectors’ words, 102 words
“Observed in Record Review. In 2 out of 3 active patient records reviewed, the organization failed to plan the patient’s care with measurable and time specific goals. On RRHV #2, it was noted that goals were not time specific with examples of No fall episode and Altered skin will heal for patient comfort. On review of RRHV #3, it was noted that goals were not measurable and specific with examples of Pt will have adequate food and fluids as tolerated or desired and Pt will have adequate food and fluids to maintain comfort. This was discussed and reviewed with the DCPS designee.”
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Content of plan of care (42 CFR 418.56(c)(2))
“Observed in Record Review. In 2 of 3 discharged records reviewed, the organization did not get a physician order for discharge. On review of RRDC #2 and RRDC #3, it was noted that the administrator called both patients and notified them Medicare was not covering care and they were being discharge with no physician order obtained for the discharge. This finding was reviewed and discussed with DCPS designee.”
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Content of plan of care (42 CFR 418.56(c)(4))
“Observed in Record Review. In 1 of 3 active patient records reviewed, the hospice nurse surveyor noted medication orders were not clear and accurate. On RRHV # 3 the physician’s orders in the plan of care documented Tylenol 500 mg cap Q6prn for mild pain and Tylenol 650mg suppository Q 6 PRN mild pain; however, there was no indication how to handle the duplicate therapy. This was discussed with the DCPS designee.”
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Coordination of services (42 CFR 418.56(e)(4))
“Observed in Record Review. On 2 of 3 live discharged records reviewed, the organization did not coordinate care and services with the interdisciplinary team. On RRDC #2 and RRDC #3, it was not discussed with the IDG team regarding discharging patients from service because they didn’t qualify for Medicare. This finding was reviewed with the DCPS designee”
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Program scope (42 CFR 418.58(a)(1))
“Observed in Data Session. On review of the QAPI program, the hospice did not include issues related to palliative outcomes in their QAPI program because they had not set up their program. This was reviewed by the DCPS designee.”
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Program data (42 CFR 418.58(b)(1))
“Observed in Data Session. On review of the QAPI program, the hospice did not use quality indicator data in the design of its QAPI program because they had not set up a program. This was reviewed by the DCPS designee.”
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Program data (42 CFR 418.58(b)(2)(i))
“Observed in Data Session. On review of the organizations QAPI program, the hospice had not collected data prior to August 2025 so they could not determine if effectiveness or safety was achieved. This was confirmed by the DCPS designee.”
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Program data (42 CFR 418.58(b)(2)(ii))
“Observed in Data Session. On review of the organizations QAPI program, the organization had not been collecting data until August 2025 so it could not be analyzed or used to identify performance trends or variances. This was confirmed by the DCPS designee. Observed in Data Session. On review of the organizations QAPI program, the agency had been collecting data but it was not being aggregated, trended or analyzed so therefore it was not being utilized to identify areas for process improvement. This was confirmed by the DCPS designee.”
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Program data (42 CFR 418.58(b)(3))
“Observed in Data Session. During review of the organizations QAPI program, it was noted the organization did not specify the detail and frequency the organization would collect data and have the governing board approval for that frequency. This was confirmed by the DCPS designee.”
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Program activities (42 CFR 418.58(c)(1)(i))
“Observed in Data Session. On review of the QAPI program, leadership had not established any performance improvement activities that affect palliative outcomes, safety or quality of care. This was reviewed by the DCPS designee.”
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Program activities (42 CFR 418.58(c)(2))
“Observed in Data Session. On review of the QAPI program, the organization did not collect data on adverse patient events, prior to August 2025. This was confirmed by the DCPS designee.”
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Performance improvement projects (42 CFR 418.58(d)(2))
“Observed in Data Session. On review of the QAPI program, the hospice had not identified any performance improvement projects and therefore had no documentation for reasons to conduct the project or measurable progress. This was reviewed by the DCPS designee.”
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Executive responsibilities (42 CFR 418.58(e)(2))
The inspectors’ words, 91 words
“Observed in Data Session. On review of the QAPI program, the agency had not collected data to be analyzed and had no performance improvement plans in place to have any improvement. This was reviewed by the DCPS designee. Observed in Data Tracer. On review of the QAPI program, the hospice had not developed a data-based performance improvement program, hence leadership did not set priorities for data collection. The organization has recognized the deficit and started an assessment and collecting data in August of 2025. This was reviewed by the DCPS designee.”
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Control (42 CFR 418.60(b))
“Observed in Infection Control System Tracer. On review of the organization Infection control, the organization failed to implement activities for infection surveillance. On review of the organization’s QAPI and Infection control program there was no data for infections collected data prior to August 2025. This was reviewed with the DCPS designee.”
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Control (42 CFR 418.60(b)(2)(ii))
“Observed in Infection Control System Tracer. During QAPI session, it was noted the organization did not have documented hand hygiene goals for 2025, 2024 and 2023 and subsequently, no data regarding improvements in hand hygiene compliance. They have started collecting data as of August 2025. This was reviewed with the DCPS designee.”
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Counseling services (42 CFR 418.64(d)(1)(i))
The inspectors’ words, 127 words
“Observed in Record Review. The surveyor found from January 2025 to August 2025 there had been no evidence of functional bereavement program that was addressing the care of the bereaved clients. The prior leadership decided to stop seeing patients and there was a gap in services being performed and the follow-up for bereavement was not done. This gap in services was discovered during the survey process, when on review of charts and discussion with leadership and the current bereavement coordinator, patient are not receiving the follow-up. The agency has hired a new bereavement coordinator as of August 2025 but on discussion with him during the survey he was just assigned the role and had no tools to do bereavement yet. This was reviewed with the DCPS designee.”
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Counseling services (42 CFR 418.64(d)(1)(iii))
“Observed in Record Review. In 1 of 2 bereavement records reviewed, bereavement services did not demonstrate the needs of the bereaved were being met. Upon review of RRBR #2, it was noted there was no bereavement plan of care developed, only one mailing sent right after death and no documented communication with the bereaved to validate whether the needs of the bereaved were being met. This was reviewed with the DCPS designee.”
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Counseling services (42 CFR 418.64(d)(1)(iv))
“Observed in Record Review. In 1 of 2 patient records where the patient had passed away on service, the bereavement plan of care was not developed. Agency bereavement policy (4-049) states that after the patient has passes away a bereavement plan for interventions will be developed. On review of RRBR #2, it was noted that patient had passed away 11 months ago and no bereavement plan was initiated for the bereaved. This finding was reviewed with the DCPS designee.”
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Cost saving (42 CFR 418.78(d))
“Observed in Tracer Activities. During review of the Volunteer program, there was no documentation to validate cost savings had been achieved using volunteers. In discussion with the Volunteer Coordinator, there was a gap without a volunteer coordinator and the reports were not completed. They have recognized the deficit and have the cost savings report for the last two months. This was reviewed and validated with the DPCS designee.”
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Level of activity (42 CFR 418.78(e))
“Observed in Tracer Activities. Identified during the review of the Volunteer Program, the organizing is not providing volunteers that equals 5% of the total patient care hours of all paid hospice employees and contract staff. There is no documentation of volunteer hours prior to August 2025 and currently they are only at 2.5 % for their hours. This was reviewed and validated with the DPCS designee.”
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Discharge or transfer of care (42 CFR 418.104(e)(1)(i))
The inspectors’ words, 99 words
“Observed in Record Review. In 3 of 3 patient records reviewed that had a live discharge, the organization failed to provide a written discharge summary in accordance with their policy. Agency policy (4-076) states that a discharge summary will be sent to attending physician. On RRDC #1, the discharge summary was created but there is no record of it being sent to the physician. On review of RRDC #2 and RRDC #3, it was noted that the discharge summary was not sent to the physician when the patient was discharged. This finding was reviewed and discussed with DCPS designee.”
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Label dispose storage drugs (42 CFR 418.106(e)(2)(i))
“Observed in Tracer Activities. On review of the organizations controlled substance policy and procedures, the organization did not have a process in place for the disposal of controlled substances for the family, the section of the policy manual was a page from the vendor stating insert organizations drug disposal instructions here and there was no insert. This finding was reviewed with the DPCS designee.”
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Label dispose storage drugs (42 CFR 418.106(e)(2)(i)(A))
“Observed in Tracer Activities. On review of the admission packet and controlled substance policy and procedures, the organization did not provide a copy of the organizations written policy and procedure. The organization has been giving instructions that have been developed in their admission binder on the disposal of controlled drugs but it did not match a policy or procedure. This finding was reviewed with the DPCS designee.”
All 3 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Feb 17, 2026 | Follow-up inspection by The Joint Commission | 4 deficiencies cited |
| Dec 18, 2025 | Follow-up inspection by The Joint Commission | No deficiencies cited |
| Nov 6, 2025 | Initial inspection by The Joint Commission | 28 deficiencies cited |
Is it certified?
- Medicare-certified hospice since Jan 5, 2022.
- CMS doesn’t list its type of ownership.
- Cited at 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. in the last three years: it didn’t meet a whole condition of Medicare’s rules.
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?
- CMS hasn’t published nursing time from Medicare claims for this hospice.
- Where its patients were cared for (Jan 1, 2024 to Dec 31, 2024): 100% in assisted living.
CMS, Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
Who owns it?
- 8 owners or officers are people: Marisol Leyva (owns 5% or more directly, 50%); Marisol Leyva (corporate officer, 50%); Marisol Leyva (corporate director, 50%); Marisol Leyva (runs it (operational or managerial control), 50%); Victor A Zunga (owns 5% or more directly, 50%); Victor A Zunga (corporate officer, 50%); Sieghart Hans Ponhold (managing employee (under contract), 0%); Daisy Pablo (managing employee (on the payroll), 0%).
- 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 gives no Hospice Care Index for this hospice.
CMS, CAHPS Hospice Survey and Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
How does it compare nearby?
- Of the 151 hospices CMS’s data show serving patients in ZIP code 91204, where this hospice’s office is, the middle number of deficiencies cited in the last three years was 4; this one had 32.
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 |
|---|---|
| Sunny Days Hospice Care Inc. | Not given |
| Breeze of Life, Inc. | Not given |
| Olympia Hospice and Palliative Care | 13 |
| First American Hospice, Inc. | Not given |
| Faith & Life Hospice Inc. | 2 |
| Uni Hospice, Inc. This hospice | 32 |
| Hp Hospice Care, Inc. | 2 |
| Primal Care Hospice, Inc. | 2 |
| Legacy of Tender Care Hospice, Inc. | 14 |
| Ajd Hospice, Inc. | 2 |
| Eclipse Hospice Care, Inc. | 17 |
| Angel’s Caring Hands Hospice Care | 3 |
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.