Fullerton Skilled Nursing Facility LLC

Enrollment entity

Provider / enrollment organization Enrollment PAC 5890143655 Enrollment ID O20231205000802

Linked facilitiesFacilities

StatesStates

15 parties: 7 organizations · 8 individuals

Owners & control parties

Name	Owner/control PAC	Type	Role(s)	%
Cibc Bank Usa	8426229584	Organization	5% or Greater Security Interest; Operational/Managerial Control	100
Legacy Healthcare Financial Services LLC	5799046132	Organization	Operational/Managerial Control; ADP of the SNF	—
Louise Dihiansan	1153779913	Individual	Operational/Managerial Control; ADP of the SNF	—
Menachem Shabat	3072526219	Individual	Operational/Managerial Control; Managing Control - Governing Body; ADP of the SNF	—
Rajesh Iyengar	3274591821	Individual	Operational/Managerial Control; ADP of the SNF	—
Gpn Family Trust U/A/D 4/28/08	5294988994	Organization	5% or Greater Direct Ownership Interest; ADP of the SNF	59.5
Doros Generation Trust U/A/D 1/3/12	6901110428	Organization	5% or Greater Direct Ownership Interest; ADP of the SNF	25.5
Oakway Operations LLC	6103212279	Organization	5% or Greater Direct Ownership Interest	15
Unknown party	7517450323	Individual	Indirect Ownership Interest	4.9
Unknown party	8426541236	Individual	Indirect Ownership Interest	4.9
Unknown party	0244723054	Individual	Indirect Ownership Interest	2.6
Unknown party	9335632140	Individual	Indirect Ownership Interest	2.6
Fullerton SNF Property Holdings LLC	2365935178	Organization	5% or Greater Security Interest; ADP of the SNF	100
Roth & Co, LLP	3173053162	Organization	ADP of the SNF	—
Unknown party	5092208801	Individual	ADP of the SNF	—

Cibc Bank UsaPAC 8426229584
Organization1005% or Greater Security Interest; Operational/Managerial Control
Legacy Healthcare Financial Services LLCPAC 5799046132
OrganizationOperational/Managerial Control; ADP of the SNF
Louise DihiansanPAC 1153779913
IndividualOperational/Managerial Control; ADP of the SNF
Menachem ShabatPAC 3072526219
IndividualOperational/Managerial Control; Managing Control - Governing Body
Rajesh IyengarPAC 3274591821
IndividualOperational/Managerial Control; ADP of the SNF
Gpn Family Trust U/A/D 4/28/08PAC 5294988994
Organization59.55% or Greater Direct Ownership Interest; ADP of the SNF
Doros Generation Trust U/A/D 1/3/12PAC 6901110428
Organization25.55% or Greater Direct Ownership Interest; ADP of the SNF
Oakway Operations LLCPAC 6103212279
Organization155% or Greater Direct Ownership Interest
Unknown partyPAC 7517450323
Individual4.9Indirect Ownership Interest
Unknown partyPAC 8426541236
Individual4.9Indirect Ownership Interest
Unknown partyPAC 0244723054
Individual2.6Indirect Ownership Interest
Unknown partyPAC 9335632140
Individual2.6Indirect Ownership Interest
Fullerton SNF Property Holdings LLCPAC 2365935178
Organization1005% or Greater Security Interest; ADP of the SNF
Roth & Co, LLPPAC 3173053162
OrganizationADP of the SNF
Unknown partyPAC 5092208801
IndividualADP of the SNF

Facility	Location	Role / stake	HPRD	Ratings	Census	Flags
Avantara Lincoln Park Fullerton Skilled Nursing Facility LLC 223 residents		Other disclo…	3.25	Ovr★★☆☆☆Stf★★☆☆☆Ins★★☆☆☆QM★★★☆☆	223

Avantara Lincoln Park
Fullerton Skilled Nursing Facility LLC
Other disclosed role223 res3.25 HPRD
Overall 2Staffing Staff 2

1 CMS ownership change record (showing 1)

Effective	Facility	Buyer	Seller	Side
10/06/2023	Avantara Lincoln Park	Fullerton Skilled Nursing Facility LLC	Symphony Lincoln Park LLC	Buyer

10/06/2023
Avantara Lincoln Park (Buyer)
Symphony Lincoln Park LLC → Fullerton Skilled Nursing Facility LLC

Related CMS associates

Name match to Fullerton Skilled Nursing Facility LLC in FEC filings. Similar names may appear—confirm on FEC.gov.