Windsor Terrace Healthcare Center

    7447 Sepulveda Blvd, Van Nuys, CA, 91405
    • Assisted living
    • Memory care
    • Skilled nursing
    AnonymousLoved one of resident
    2.0

    Compassionate staff, systemic neglect, theft

    My stay was deeply mixed. Some nurses, CNAs and therapists (Estella Benitez, Diana, Christina and others) were compassionate, professional and excellent in rehab - clean rooms, good activities and great therapy when staff were present. But I experienced theft by staff (belongings taken, not reimbursed, found later on camera), frequent unresponsiveness, long waits for basic needs, missed/late meds, poor wound care and infections, dirty/poorly maintained rooms and dangerous understaffing. In short: exceptional individual caregivers exist, but systemic neglect, safety and theft issues mean I would be very cautious and insist on a strong advocate before trusting a high-risk loved one here.

    Pricing

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Restaurant-style dining
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (non-medical)

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    3.45 · 110 reviews

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      3.4
    • Staff

      3.5
    • Meals

      3.2
    • Amenities

      2.4
    • Value

      1.0

    Pros

    • Excellent physical, occupational, and speech therapy services
    • Many caring and attentive CNAs and nurses praised by families
    • Several staff members and administrators identified as very helpful (e.g., Cristina Castro, Ana, Estella Benitez, Jose Gutierrez, Muty)
    • Admissions and marketing staff often provide smooth transitions and personalized guidance
    • Clean rooms and daily housekeeping reported by multiple reviewers
    • Rehabilitation-focused environment with good recovery outcomes for many
    • Supportive social services and helpful communication (daily updates, FaceTime outreach)
    • Pleasant activities program (music, entertainment, events) and engaged activity staff
    • Good variety and generally ample food; some reviewers found meals tasty and nutritious
    • Welcoming lobby and home-like atmosphere noted by many residents/families
    • Some very responsive nursing staff with fast response times reported
    • Helpful therapists and effective wound specialist acknowledged in positive cases
    • Professional, compassionate management and staff reported by multiple families
    • Safe, orderly, well-maintained areas cited by some reviewers
    • Personalized attention and family-style care appreciated by many

    Cons

    • Inconsistent care quality across shifts and staff members
    • Frequent reports of neglect: ignored call lights, long waits for assistance, skipped baths
    • Missed, delayed, or incorrect medication administration (delays of 2–5 hours reported)
    • Serious wound care failures and infections leading to hospital/ICU admissions in some cases
    • Allegations of abuse/shaming: yelling at residents, scolding for soiling, unsanitary care
    • Understaffing and staff shortages contributing to poor care and long response times
    • Theft and missing personal belongings by staff (purse theft, items found in dumpster)
    • Poor or unsafe facility conditions in some areas (peeling walls, drapes/furnishings falling, broken beds/equipment)
    • Dirty rooms, foul odors (feces/urine), and inadequate laundry practices cited by multiple reviewers
    • Inadequate or poor-quality food for some residents (undercooked, poor texture, insufficient nutrition)
    • Poor communication and unresponsiveness from some nurses and reception staff
    • Profit-driven administration accusations and perceived prioritization of aesthetics over care
    • Registry/agency nurses perceived as incompetent or unsupervised
    • Safety and security concerns: misplaced wheelchairs, belongings, and inconsistent monitoring
    • Pressure to provide positive reviews and marketing-driven VIP treatment reported
    • Language barriers and monolingual staff limiting effective communication for some families
    • Reports of management unprofessionalism and instances of staff using foul language
    • Incomplete or misleading marketing/photos vs. actual room conditions
    • Patients being discharged prematurely or pressured to leave
    • Instances of inconsistent diet/special-diet provision and missed meals

    Summary review

    Overall sentiment in the reviews for Windsor Terrace Healthcare Center is highly mixed and polarized. A substantial portion of reviewers report outstanding, even life-changing, rehabilitative care: strong physical, occupational, and speech therapy programs; skilled therapists and a wound specialist; attentive CNAs and nurses; and admissions/marketing staff who create smooth, comforting transitions. Many families describe rooms as clean, an inviting lobby and home-like atmosphere, a robust activity program, and generally good food. Specific staff members and administrators (several names recur) receive repeated, enthusiastic praise for going above and beyond, providing daily updates, and treating residents like family. For these residents, Windsor Terrace functions as an excellent recovery-focused facility with compassionate staff and effective therapy that leads to measurable improvement.

    Counterbalancing those positive accounts are numerous and serious negative reports describing neglect, unsafe clinical care, and institutional problems. Commonly cited issues include understaffing, long response times to call lights, skipped showers or baths, missed or significantly delayed medications, and inconsistent staffing quality—particularly when registry or agency nurses are on duty. Several reviewers recount alarming clinical failures: wounds left wet or unredressed leading to infections, delays in emergency response, and readmissions to hospital or ICU. These are not isolated complaints; they indicate systemic lapses in basic nursing care and wound management for some residents.

    Safety, security, and facility condition are recurring concerns. Multiple reviewers report theft or misplaced belongings (including a purse reportedly taken by staff and later found in a dumpster), missing wheelchairs, and overall security lapses that led to police involvement in at least one case. Physical plant problems are also mentioned: peeling wall coverings, broken beds or armrests, drapes hanging off windows, malfunctioning equipment, and inconsistent cleanliness—while other reviewers describe the facility as clean and pleasantly scented. This dichotomy suggests variability by unit, room, or time period rather than a uniform facility standard.

    Dining and nutrition feedback is similarly split. Some residents praise ample, tasty meals and highlight attentive dining staff and an involved executive chef. Others report poor-quality food, undercooked items, insufficient protein, or meals that were improperly prepared (e.g., ground foods that tasted bad), leading to inadequate intake. Special-diet management also appears inconsistent for some new admissions, contributing to nutritional and recovery issues for vulnerable residents.

    Communication and administration receive both accolades and criticism. Several families single out admissions personnel and specific administrators for compassionate, hands-on support, effective coordination with families, and advocacy. Conversely, other reviewers describe profit-driven priorities, pressure to leave or to post positive reviews, unresponsiveness from reception, and monolingual staff creating barriers to clear communication. There are allegations that marketing or VIP arrival experiences may not reflect ongoing care quality, and some reviewers suggest care declined after ownership changes.

    A strong pattern emerges around variability: care quality, cleanliness, staffing competence, and responsiveness appear to depend heavily on particular shifts, individual staff members, and perhaps specific units. Many reviews emphasize that when the core staff are present and engaged—therapists, CNAs, admissions liaisons, and particular nurses—the facility can deliver outstanding, compassionate care. When those staff are absent or when agency personnel are used, families report significant safety and quality problems. This inconsistency is compounded by reported understaffing and inadequate supervision, which reviewers link to missed medications, delayed assistance, and insufficient wound care.

    Notable severe concerns that demand attention include multiple reports of neglect leading to worsening health or hospital readmission, documented theft and security lapses, and instances of alleged abuse or demeaning treatment of residents. These issues go beyond service dissatisfaction and raise questions of resident safety, regulatory compliance, and staff training/supervision. At the same time, many positive reports indicate genuine strengths in rehabilitation services, certain compassionate staff members, and family-focused admissions processes.

    In summary, Windsor Terrace Healthcare Center appears to deliver excellent care for some residents—especially those receiving active rehabilitation services and who interact with committed staff members—but it also exhibits serious, recurring shortcomings that have led to harm for other residents. The dominant themes are inconsistency and uneven execution: high-quality therapy, engaged admissions liaisons, and standout caregivers coexist with undertrained or inattentive staff, clinical neglect, security incidents, and variable facility conditions. Anyone evaluating Windsor Terrace should weigh both sets of experiences, ask specific questions about staffing ratios, turnover, supervision of registry nurses, wound-care protocols, incident reporting and follow-up, security measures, meal and special-diet processes, and on-shift leadership. Families considering the facility would be wise to ask for names of consistent primary caregivers, observe multiple shifts if possible, request recent inspection or incident reports, and maintain active advocacy and communication channels while their loved one is in residence.

    Location

    Map showing location of Windsor Terrace Healthcare Center

    About Windsor Terrace Healthcare Center

    Windsor Terrace Healthcare Center holds a Medicare/Medi-Cal certification and runs 133 licensed certified beds, though on an average day you'll find about 116 residents staying there, and you'll notice the nurse staffing works out to about 3.92 nurse hours per resident per day, which is a detailed way of saying there tend to be nurses around but sometimes they do see a nurse turnover rate of 38.3%, and as with any place, ownership is a bit of a web, with Windsor associated and direct ownership by Antelope Holdings I, LLC, plus several indirect owners including Pico Ar LLC and the names Aaron Robin and Avrohom Tress, but they haven't given details about who exactly manages or runs the daily workings and there have been 119 deficiencies noted over inspections, with about 9 tied to infection control and a notable complaint from March 2025, related to a quality of life and care incident, and there have been citations, including one for failing to prevent unnecessary loss of daily abilities and one for missing the standards for infection prevention and control, so it's fair to say that inspectors have called attention to these matters, and still, the facility is clean and focused on offering care for long-term health, rehabilitation, and memory care, as well as independent living, assisted living, and more for seniors who need help with daily activities like bathing and medication management, and you'll see friendly staff around and get the sense of a culture that values respect and kindness, with a set up that aims for a homelike feeling, and the place has a five-star Medicare rating for quality measures, so while there have been issues, there are also strengths, like skilled nursing available around the clock, a secured memory care unit for people with Alzheimer's or dementia, and rehabilitation programs for physical, occupational, and speech therapy, even including Respiratory, Pet, Infusion, IV, and Ultrasound therapy, and post-hospital, sub-acute, and complex wound care for those who need extra healing, and then in the everyday details, every room has TV, cable, phone hookups, WiFi, and new wood floors, with private rooms for those who want them, open courtyards for fresh air, and extras like movies, Nintendo Wii Fit sessions, hair salon, business help, spiritual services, plus all sorts of daily activities, outings, parties, and a resident council to help people stay involved, and you'll also see meal plans directed by doctors, regular nutrition checks by a dietitian, and meals made with good ingredients, and for anyone thinking about moving in, tours run daily, and family can send cheery greetings too, and while it's important to know the place has had a history of federal deficiencies including infection control and quality of life care, there are also lots of programs and staff in place to try and keep residents comfortable, active, and as independent as they can be.

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