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 sampled resident with a permacath for hemodialysis treatment, which could delay emergency intervention and potentially cause life-threatening complications.

The facility failed to remove a pressure dressing and document the condition of hemodialysis access sites for three residents, placing them at risk for infection and circulation issues. Additionally, the facility failed to provide a soft and bite-sized texture diet as ordered for one resident, placing the resident at risk of choking and aspiration.

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 revealed that Staff 1 was hired as a Licensed Vocational Nurse (LVN) without a valid professional LVN license and administered controlled substances to multiple residents over a period exceeding one and a half years. The facility failed to verify the license at hiring and allowed unlicensed practice, resulting in increased risk of medication errors and unsafe care.

The facility allowed an unlicensed nurse to administer controlled substances and other medications to multiple residents, posing significant risks including medication errors, unsafe care, and potential harm. The facility failed to verify Staff 1's LVN license prior to hiring, violating policies and placing residents at risk.

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 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 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 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 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 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 complaint involved failure to notify the physician of Resident 2's refusal of seizure medication and failure to timely report an allegation of abuse involving Resident 1. The abuse allegation was substantiated as staff failed to report the incident within two hours as required.

The facility failed to notify the physician when Resident 2 refused seizure medication, resulting in an unwitnessed fall and ankle fracture. Additionally, the facility staff failed to report an allegation of abuse involving Resident 1 within the required two-hour timeframe. Both deficiencies posed risks of harm to residents.

The facility was found deficient in multiple areas including failure to provide dignified care, inadequate call light response, insufficient staffing, improper care planning, unsafe equipment, infection control lapses, improper medication storage, dietary deficiencies, and failure to follow vaccination protocols.

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 investigation substantiated that Resident 1 was verbally and physically abused by CNA 1 on 10/16/23. The CNA was terminated on 10/18/23 after the facility's investigation.

The facility failed to ensure one resident was free from verbal and physical abuse by CNA 1, who struck the resident with a phone after being spat upon. CNA 1 was terminated following the facility's investigation.

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 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.