Inspection Reports for
Avalon Villa Care Center

The facility was found deficient in obtaining informed consent for administering Depakote to a resident, failed to monitor the effectiveness of psychotropic medication for one resident, and did not provide adequate space for wheelchair maneuvering for two residents, resulting in resident frustration and safety concerns.

The complaint investigation was substantiated with findings that the facility failed to provide timely incontinence care, develop and update care plans appropriately, transcribe physician orders accurately, and maintain accurate medication administration documentation.

The facility failed to provide timely incontinence care to residents, resulting in discomfort and risk of skin breakdown. Care plans were not developed or updated timely to address residents' needs and noncompliance. The facility failed to transcribe a non-weight bearing order into the electronic health record, risking delayed wound healing. Medication administration documentation was inaccurate, including failure to notify physicians when holding medications, leading to potential untreated conditions and adverse effects.

The facility failed to ensure a Hemodialysis Emergency Kit was present at the bedside of one resident with a permacath for hemodialysis treatment, potentially delaying emergency intervention during complications.

The facility was found deficient in providing appropriate treatment and care related to hemodialysis access site dressing removal and documentation for three residents, and in ensuring one resident received a diet prepared in a soft and bite-sized texture as ordered. These deficiencies posed risks of infection, impaired circulation, choking, aspiration, and possible severe health complications.

The facility was found deficient in multiple areas including failure to ensure timely changing of a resident in soiled diapers, delayed response to call lights, kitchen staff not wearing proper hair coverings, and ineffective pest control resulting in live cockroach sightings in resident-accessible areas.

The complaint investigation substantiated that Staff 1 was hired and worked as a Licensed Vocational Nurse without a valid professional license for over a year and a half, administering controlled substances and other medications to multiple residents, which posed significant risks to resident safety.

The facility allowed an unlicensed nurse (Staff 1) to administer medications, including controlled substances, to multiple residents for over one and a half years. This practice posed significant risks of medication errors, unsafe care, and potential harm to residents, and the facility failed to properly verify Staff 1's licensure before hiring.

The complaint investigation involved Resident 1 who was receiving psychotropic medication without behavior monitoring, reported verbal abuse by staff and residents that was not timely reported to authorities, and lacked a care plan for major depressive disorder. Staff RN 1 and LVN 1 lacked knowledge of abuse reporting requirements and the facility's abuse coordinator. The allegations were substantiated as deficiencies.

The facility failed to monitor behavior for a resident receiving psychotropic medication, did not timely report allegations of abuse, failed to develop a care plan addressing major depressive disorder for a resident, and nursing staff demonstrated lack of competency regarding abuse reporting requirements. These deficiencies placed residents at risk of harm and abuse.

The complaint investigation was triggered by an incident on 7/19/2025 where an employee (CNA 1) was beaten by three unidentified males who allegedly gained access to the facility using a gate code known by another employee (CNA 2). The facility failed to change the gate code after the incident, placing residents and staff at risk. Additionally, infection control deficiencies were found related to colostomy care for Resident 1.

The facility failed to change the gate code after the assault incident, placing residents and staff at risk of harm. Also, the facility failed to implement proper infection prevention and control measures during colostomy bag changes for a resident, including failure to wash hands and change gloves appropriately, increasing risk of infection.

The facility failed to implement an individualized person-centered care plan for Resident 1 addressing behaviors of entering other residents' rooms and taking belongings, and failed to document reporting a change of condition for Resident 2 to the attending physician and psychiatrist. Both deficiencies had the potential to negatively affect resident care and communication.

The complaint investigation found substantiated deficiencies related to failure in care planning and clinical record documentation for two residents.

The facility failed to develop a care plan addressing Resident 1's behavior of entering other residents' rooms and taking belongings, and failed to document reporting a change of condition for Resident 2 to the attending physician and psychiatrist. These deficiencies had the potential to negatively affect care delivery and communication.

The facility failed to provide daily dietary menus to residents unable to get out of bed, violating their rights to dignity and informed food choices. Additionally, a medication cream was left unattended at a resident's bedside, posing a risk of accidental misuse.

The investigation was complaint-driven, focusing on allegations that residents were not provided with dietary menus and that medication was left unattended. The findings substantiated these complaints.

The facility failed to provide daily dietary menus to two residents who required assistance to get out of bed, violating their rights to dignity and informed food choices. Additionally, the facility left Zinc oxide cream unattended at a resident's bedside, posing a risk of accidental misuse.

The facility failed to ensure that a resident had a completed Release of Responsibility form before leaving on pass, resulting in lack of knowledge about the resident's whereabouts and return time. Additionally, the facility failed to properly label, date, and seal thawing and opened food items in the kitchen refrigerator, posing a risk for foodborne illnesses.

The facility failed to ensure licensed nurses had the appropriate competencies and skill sets, specifically regarding a registered nurse (RN 1) whose license was on probation and whose competencies were not fully verified. Additionally, the facility failed to maintain accurate and timely clinical documentation for a sampled resident (Resident 1), particularly regarding vital signs and change of condition records.

The investigation was complaint-driven, focusing on nursing competencies and documentation accuracy. The complaint was substantiated with findings of license probation violations and inaccurate medical record documentation.

The facility failed to ensure licensed nurses had the appropriate competencies and skill sets, specifically regarding a registered nurse (RN 1) on probation with incomplete competency assessments. Additionally, the facility failed to maintain accurate and timely documentation of a resident's vital signs and change of condition.

The facility was found deficient in several areas including failure to accommodate a resident's room change request, failure to develop and implement individualized care plans for skin conditions, failure to provide appropriate treatment and follow physician orders, medication administration errors, and failure to maintain safe and comfortable restroom environments. These deficiencies resulted in minimal harm or potential for harm to residents.

The complaint investigation was substantiated, revealing failures in room change accommodation, care planning, medication administration, and environmental safety.

The facility failed to reasonably accommodate a resident's request for a room change, develop and implement an individualized care plan for a resident with severe skin conditions, ensure timely administration of scheduled medications for another resident, and maintain safe and comfortable restroom environments. These deficiencies resulted in resident discomfort, worsening health conditions, and potential safety risks.

The complaint investigation included substantiated findings related to resident rights violations, failure to obtain informed consent, call light accessibility issues, failure to report elopements and trespassing, unsafe discharges, inaccurate assessments, incomplete care plans, medication administration errors, infection control breaches, and food service deficiencies.

The facility was found deficient in multiple areas including failure to honor resident rights, obtain informed consent for medications, ensure call light accessibility, timely report elopements and trespassing incidents, safely discharge residents, accurately complete assessments, develop comprehensive care plans, provide accurate meal documentation, maintain infection control, and ensure proper medication administration and monitoring.

The facility was found deficient in multiple areas including failure to accommodate resident requests, obtain informed consent for medications, monitor residents at risk for wandering and elopement, ensure safe discharges, accurately complete assessments, provide appropriate care plans, maintain medication administration and documentation, ensure food safety and proper diet preparation, maintain infection control, and ensure staff competency evaluations. Immediate jeopardy was identified related to resident elopement and unsafe environment due to a resident trespassing with a weapon.

The facility failed to ensure staff properly wore personal protective equipment (PPE) such as N95 masks and face shields, which posed a risk of Covid-19 transmission to residents, staff, and visitors.

The investigation was complaint-related, focusing on improper PPE use by staff during a Covid-19 outbreak. The deficiency was substantiated with observations and interviews confirming staff did not wear PPE correctly.

The facility failed to ensure staff properly wore personal protective equipment (PPE) such as N95 masks and face shields during a Covid-19 outbreak, increasing the risk of virus transmission among residents, staff, and visitors.

The complaint involved failure to notify the physician about medication refusal by Resident 2, failure to report alleged abuse of Resident 1 timely, and failure to implement the care plan after medication refusal leading to injury. The allegations were substantiated based on interviews, record reviews, and observations.

The facility failed to notify the physician when a resident refused seizure medication, failed to immediately report alleged abuse to the administrator and authorities, and failed to implement the care plan after a resident's refusal of seizure medication, resulting in an unwitnessed fall and injury.

The facility was found deficient in multiple areas including failure to provide dignified care, inadequate call light response, insufficient staffing especially during night shifts, failure to develop and implement appropriate care plans, improper management of resident equipment and medications, unsafe environment and supervision, infection control lapses, and failure to follow dietary and nutritional standards.

The facility failed to revise the comprehensive care plans for two of three sampled residents (Resident 2 and Resident 3) to address their episodes of verbal and physical aggression towards others. This deficiency had the potential to negatively impact the delivery of nursing care and medical interventions for these residents.

The complaint investigation found that Resident 1 exhibited verbal aggression at 2:41 PM on 11/26/2023, which was not addressed with a care plan update. This led to a physical altercation at 7:05 PM involving Resident 1, Resident 2, and Resident 3. Staff were unaware of the need for monitoring, and no supervision was present on the smoking patio during the incident. The complaint was substantiated based on interviews and record reviews.

The facility failed to develop and update a care plan for Resident 1 following verbal aggression, resulting in lack of staff awareness and supervision. This led to a physical altercation involving Resident 1, Resident 2, and Resident 3, creating potential physical and psychosocial harm. Interviews and record reviews confirmed inadequate monitoring and failure to update care plans as required by facility policies.

The complaint investigation was substantiated by findings that the facility did not report alleged physical abuse incidents involving Resident 1 to the Department of Public Health, Licensing and Certification unit, or local police. The Director of Nursing was informed of the incidents but did not report them, considering them customer care issues. Resident 1 and family members reported abuse, including a remote control hitting the resident's face and use of scalding hot water during care.

The facility failed to report two separate allegations of physical abuse to the appropriate authorities, resulting in delayed investigation and potential continued harm to Resident 1. The Director of Nursing did not report the incidents, deeming them customer care issues rather than abuse, despite evidence and family concerns.

The complaint was substantiated. The investigation found that the CNA verbally abused the resident and physically struck him with a phone after the resident spat at her. The CNA was terminated on 10/18/23 following the investigation.

The facility failed to ensure one resident was free from verbal and physical abuse by a CNA. The CNA was observed to have struck the resident with a phone after being spat upon, and was subsequently terminated following the facility's investigation.

The complaint investigation substantiated that the facility did not monitor Resident 1 adequately after aggressive incidents, including pushing another resident to the floor and threatening staff with a plastic knife. The facility acknowledged incomplete care planning and lack of increased monitoring interventions.

The facility failed to update the care plan to monitor Resident 1 for aggressive verbal and physical behavior, resulting in potential risk of further abuse and injury to residents and staff. Interviews and record reviews confirmed Resident 1's escalating aggressive behavior and lack of appropriate monitoring interventions.

The facility failed to revise Resident 1's comprehensive care plan to include increased monitoring for aggressive verbal and physical behavior, resulting in potential risk of further abuse or injury to residents and staff. The care plan revisions were incomplete and did not specify interventions such as 1:1 monitoring or monitoring every 15 minutes.

The facility staff failed to perform hand hygiene before administering wound treatment to one of three sampled residents, which posed a risk of infection and impaired healing. The facility's policy on hand hygiene was reviewed and found to emphasize the importance of handwashing before various care activities.

The facility staff failed to perform hand hygiene before administering wound treatment to one sampled resident, which had the potential to cause infections and impede healing. The facility policy requires hand hygiene before various care activities, but this was not followed during observation.

The complaint investigation found that Resident 1 was not updated timely about his pain medication request, leading to feelings of frustration and retaliation. The licensed nurse did not follow pain medication protocol by failing to explain the medication and not reassessing pain levels after administration.

The facility failed to ensure that Resident 1 was informed about the status of his pain medication request, causing frustration and anxiety. Additionally, the licensed nurse failed to explain the pain medication administered and did not reevaluate the resident's pain level after administration, resulting in increased discomfort.

The complaint involved Resident 1 who alleged that a facility Activities Coordinator used his bank card for unauthorized purchases and withdrawals. The allegation was not reported to the State Agency (CDPH), Ombudsman, or law enforcement within the required two-hour timeframe. The facility also failed to conduct a thorough investigation or submit a written report of findings to the State Agency.

The facility failed to timely report the allegation of misappropriation to the State Agency, Ombudsman, and law enforcement within the required timeframe. Additionally, the facility did not conduct a thorough investigation nor provide a written conclusion of the investigation to the State Agency, placing residents at risk for continuous abuse.

The complaint involved an allegation that CNA 1 physically and verbally abused Resident 1 on 12/1/2022. The allegation was substantiated after investigation. CNA 1 was terminated on 12/5/2022. The facility failed to report the incident timely and failed to protect the resident from further abuse.

The facility failed to timely report the abuse allegation, did not immediately remove the perpetrator pending investigation, and did not provide in-service training to all staff shifts on Adult and Elderly Abuse Prevention and Reporting. The investigation confirmed that CNA 1 verbally and physically assaulted Resident 1, and CNA 1 was subsequently terminated.

The facility had multiple deficiencies including failure to follow resident care plans, medication administration errors, improper medication storage and labeling, incomplete care plans, inadequate infection control practices, and food safety violations.