★★★★★Overall Medicare rating
★★★★★Health inspections
★★★★★Staffing
★★★★★Quality measures
Medicare rates every nursing home from 1 to 5 stars. 5 is much above average, 1 is much below.
Findings, latest cycle22
Findings with harm or immediate jeopardy, 3 cycles2
Fines, 3 years$29,170
Beds95
Medicare has flagged this home for abuse: an inspection found that a resident was harmed by abuse, or there were repeated findings of possible abuse.
Inspection findings
Inspectors recorded 79 findings in the last three inspection cycles.
Each entry below is a requirement that inspectors found the home did not meet on that date, in the regulator's own English wording.
| Inspection date | Area | Requirement the home did not meet (official wording, in English) | Severity | Corrected |
|---|---|---|---|---|
| Feb 27, 2026 | Infection control | Implement a program that monitors antibiotic use. (F0881) | No harm, but a risk of harm isolated | Corrected: Mar 25, 2026 |
| Feb 27, 2026 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm widespread | Corrected: Mar 25, 2026 |
| Feb 27, 2026 | Resident assessment and care planning | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (F0842) | No harm, but a risk of harm isolated | Corrected: Mar 25, 2026 |
| Feb 27, 2026 | Food and nutrition | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F0812) | No harm, but a risk of harm pattern | Corrected: Mar 25, 2026 |
| Feb 27, 2026 | Quality of life and care | Provide routine and 24-hour emergency dental care for each resident. (F0790) | No harm, but a risk of harm pattern | Corrected: Mar 25, 2026 |
| Feb 27, 2026 | Pharmacy and medications | Ensure each resident’s drug regimen must be free from unnecessary drugs. (F0757) | No harm, but a risk of harm isolated | Corrected: Mar 25, 2026 |
| Feb 27, 2026 | Nursing and physician services | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. (F0726) | No harm, but a risk of harm isolated | Corrected: Mar 25, 2026 |
| Feb 27, 2026 | Quality of life and care | Provide safe, appropriate pain management for a resident who requires such services. (F0697) | No harm, but a risk of harm isolated | Corrected: Mar 25, 2026 |
| Feb 27, 2026 | Quality of life and care | Assist a resident in gaining access to vision and hearing services. (F0685) | No harm, but a risk of harm isolated | Corrected: Mar 25, 2026 |
| Feb 27, 2026 | Quality of life and care | Provide activities to meet all resident's needs. (F0679) | No harm, but a risk of harm isolated | Corrected: Mar 25, 2026 |
| Feb 27, 2026 | Quality of life and care | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. (F0676) | No harm, but a risk of harm isolated | Corrected: Mar 25, 2026 |
| Feb 27, 2026 | Abuse, neglect and exploitation | Respond appropriately to all alleged violations. (F0610) | No harm, but a risk of harm isolated | Corrected: Mar 25, 2026 |
| Feb 27, 2026 | Abuse, neglect and exploitation | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F0609) | No harm, but a risk of harm isolated | Corrected: Mar 25, 2026 |
| Feb 27, 2026 | Abuse, neglect and exploitation | Develop and implement policies and procedures to prevent abuse, neglect, and theft. (F0607) | No harm, but a risk of harm isolated | Corrected: Mar 25, 2026 |
| Feb 27, 2026 | Abuse, neglect and exploitation | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. (F0605) | No harm, but a risk of harm isolated | Corrected: Mar 25, 2026 |
| Dec 16, 2025 | Resident assessment and care planning | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F0656) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jan 8, 2026 |
| Dec 16, 2025 | Resident rights | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (F0580) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jan 8, 2026 |
| Dec 4, 2025 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm isolated · from a complaint | Corrected: Dec 11, 2025 |
| Dec 4, 2025 | Abuse, neglect and exploitation | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F0609) | No harm, but a risk of harm isolated · from a complaint | Corrected: Dec 11, 2025 |
| Dec 4, 2025 | Abuse, neglect and exploitation | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F0600) | No harm, but a risk of harm isolated · from a complaint | Corrected: Dec 11, 2025 |
Earlier inspections (59)
| Inspection date | Area | Requirement the home did not meet (official wording, in English) | Severity | Corrected |
|---|---|---|---|---|
| Nov 19, 2025 | Building and environment | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. (F0921) | No harm, but a risk of harm pattern · from a complaint | Corrected: Dec 11, 2025 |
| Nov 19, 2025 | Resident rights | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. (F0584) | No harm, but a risk of harm isolated · from a complaint | Corrected: Dec 11, 2025 |
| May 16, 2025 | Nursing and physician services | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. (F0726) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jun 11, 2025 |
| May 16, 2025 | Abuse, neglect and exploitation | Respond appropriately to all alleged violations. (F0610) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jun 11, 2025 |
| May 16, 2025 | Abuse, neglect and exploitation | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F0609) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jun 11, 2025 |
| Apr 28, 2025 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jun 25, 2025 |
| Apr 28, 2025 | Administration | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (F0867) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jun 25, 2025 |
| Apr 28, 2025 | Quality of life and care | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689) | Actual harm to a resident isolated · from a complaint | Corrected: May 21, 2025 |
| Apr 28, 2025 | Quality of life and care | Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F0684) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jun 25, 2025 |
| Apr 28, 2025 | Abuse, neglect and exploitation | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F0600) | Actual harm to a resident isolated · from a complaint | Corrected: Jun 25, 2025 |
| Mar 14, 2025 | Food and nutrition | Dispose of garbage and refuse properly. (F0814) | No harm, but a risk of harm widespread · from a complaint | Corrected: Mar 31, 2025 |
| Feb 19, 2025 | Abuse, neglect and exploitation | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F0600) | No harm, but a risk of harm isolated · from a complaint | Corrected: Mar 12, 2025 |
| Dec 20, 2024 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm pattern | Corrected: Jan 30, 2025 |
| Dec 20, 2024 | Resident assessment and care planning | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (F0842) | No harm, but a risk of harm isolated | Corrected: Jan 30, 2025 |
| Dec 20, 2024 | Food and nutrition | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F0812) | No harm, but a risk of harm widespread | Corrected: Jan 30, 2025 |
| Dec 20, 2024 | Pharmacy and medications | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. (F0761) | No harm, but a risk of harm isolated | Corrected: Jan 30, 2025 |
| Dec 20, 2024 | Pharmacy and medications | Ensure medication error rates are not 5 percent or greater. (F0759) | No harm, but a risk of harm isolated | Corrected: Jan 30, 2025 |
| Dec 20, 2024 | Pharmacy and medications | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. (F0758) | No harm, but a risk of harm isolated | Corrected: Jan 30, 2025 |
| Dec 20, 2024 | Pharmacy and medications | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F0755) | No harm, but a risk of harm isolated | Corrected: Jan 30, 2025 |
| Dec 20, 2024 | Nursing and physician services | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. (F0726) | No harm, but a risk of harm isolated | Corrected: Jan 30, 2025 |
| Dec 20, 2024 | Quality of life and care | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. (F0688) | No harm, but a risk of harm pattern | Corrected: Jan 30, 2025 |
| Dec 20, 2024 | Quality of life and care | Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F0684) | No harm, but a risk of harm isolated | Corrected: Jan 30, 2025 |
| Dec 20, 2024 | Quality of life and care | Provide care and assistance to perform activities of daily living for any resident who is unable. (F0677) | No harm, but a risk of harm isolated | Corrected: Jan 30, 2025 |
| Dec 20, 2024 | Resident assessment and care planning | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F0656) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jan 30, 2025 |
| Dec 20, 2024 | Resident assessment and care planning | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. (F0644) | No harm, but a risk of harm pattern | Corrected: Jan 30, 2025 |
| Dec 20, 2024 | Resident assessment and care planning | Ensure each resident receives an accurate assessment. (F0641) | No harm, minimal risk pattern | Corrected: Jan 30, 2025 |
| Dec 20, 2024 | Resident rights | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. (F0584) | No harm, but a risk of harm isolated | Corrected: Jan 30, 2025 |
| Dec 20, 2024 | Resident rights | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. (F0578) | No harm, but a risk of harm pattern | Corrected: Jan 30, 2025 |
| Dec 20, 2024 | Resident rights | Reasonably accommodate the needs and preferences of each resident. (F0558) | No harm, but a risk of harm isolated | Corrected: Jan 30, 2025 |
| Oct 17, 2024 | Resident rights | Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. (F0626) | No harm, but a risk of harm isolated · from a complaint | Corrected: Nov 7, 2024 |
| Feb 2, 2024 | Abuse, neglect and exploitation | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F0609) | No harm, but a risk of harm isolated · from a complaint | Corrected: Feb 20, 2024 |
| Feb 1, 2024 | Resident assessment and care planning | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F0656) | No harm, but a risk of harm isolated · from a complaint | Corrected: Feb 12, 2024 |
| Feb 1, 2024 | Abuse, neglect and exploitation | Respond appropriately to all alleged violations. (F0610) | No harm, but a risk of harm isolated · from a complaint | Corrected: Feb 12, 2024 |
| Jan 5, 2024 | Building and environment | Make sure that a working call system is available in each resident's bathroom and bathing area. (F0919) | No harm, but a risk of harm isolated | Corrected: Feb 1, 2024 |
| Jan 5, 2024 | Infection control | Develop and implement policies and procedures for flu and pneumonia vaccinations. (F0883) | No harm, but a risk of harm isolated | Corrected: Feb 1, 2024 |
| Jan 5, 2024 | Food and nutrition | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F0812) | No harm, but a risk of harm widespread | Corrected: Feb 1, 2024 |
| Jan 5, 2024 | Quality of life and care | Provide routine and 24-hour emergency dental care for each resident. (F0790) | No harm, but a risk of harm pattern | Corrected: Feb 1, 2024 |
| Jan 5, 2024 | Pharmacy and medications | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. (F0761) | No harm, but a risk of harm pattern | Corrected: Feb 1, 2024 |
| Jan 5, 2024 | Pharmacy and medications | Ensure that residents are free from significant medication errors. (F0760) | No harm, but a risk of harm pattern | Corrected: Feb 1, 2024 |
| Jan 5, 2024 | Pharmacy and medications | Ensure medication error rates are not 5 percent or greater. (F0759) | No harm, but a risk of harm pattern | Corrected: Feb 1, 2024 |
| Jan 5, 2024 | Pharmacy and medications | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. (F0758) | No harm, but a risk of harm isolated | Corrected: Feb 1, 2024 |
| Jan 5, 2024 | Pharmacy and medications | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F0755) | No harm, but a risk of harm pattern | Corrected: Feb 1, 2024 |
| Jan 5, 2024 | Quality of life and care | Provide care or services that was trauma informed and/or culturally competent. (F0699) | No harm, but a risk of harm isolated | Corrected: Feb 1, 2024 |
| Jan 5, 2024 | Quality of life and care | Provide safe and appropriate respiratory care for a resident when needed. (F0695) | No harm, but a risk of harm pattern | Corrected: Feb 1, 2024 |
| Jan 5, 2024 | Quality of life and care | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. (F0693) | No harm, but a risk of harm isolated | Corrected: Feb 1, 2024 |
| Jan 5, 2024 | Quality of life and care | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689) | No harm, but a risk of harm pattern | Corrected: Feb 1, 2024 |
| Jan 5, 2024 | Quality of life and care | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. (F0688) | No harm, but a risk of harm pattern | Corrected: Feb 1, 2024 |
| Jan 5, 2024 | Quality of life and care | Assist a resident in gaining access to vision and hearing services. (F0685) | No harm, but a risk of harm isolated | Corrected: Feb 1, 2024 |
| Jan 5, 2024 | Abuse, neglect and exploitation | Respond appropriately to all alleged violations. (F0610) | No harm, but a risk of harm pattern · from a complaint | Corrected: Feb 1, 2024 |
| Jan 5, 2024 | Abuse, neglect and exploitation | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F0609) | No harm, but a risk of harm pattern · from a complaint | Corrected: Feb 1, 2024 |
| Jan 5, 2024 | Abuse, neglect and exploitation | Develop and implement policies and procedures to prevent abuse, neglect, and theft. (F0607) | No harm, but a risk of harm pattern · from a complaint | Corrected: Feb 1, 2024 |
| Jan 5, 2024 | Abuse, neglect and exploitation | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F0600) | No harm, but a risk of harm isolated · from a complaint | Corrected: Feb 1, 2024 |
| Jan 5, 2024 | Resident rights | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (F0580) | No harm, but a risk of harm isolated | Corrected: Feb 1, 2024 |
| Dec 11, 2023 | Resident assessment and care planning | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (F0657) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jan 17, 2024 |
| Dec 11, 2023 | Resident rights | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (F0623) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jan 17, 2024 |
| Dec 11, 2023 | Resident rights | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (F0580) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jan 17, 2024 |
| Dec 11, 2023 | Resident rights | Let each resident or the resident's legal representative access or purchase copies of all the resident's records. (F0573) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jan 17, 2024 |
| Dec 11, 2023 | Resident rights | Honor the resident's right to choose his or her attending physician. (F0555) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jan 17, 2024 |
| Dec 11, 2023 | Resident rights | Ensure that residents are fully informed and understand their health status, care and treatments. (F0552) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jan 17, 2024 |
Fines and payment denials
Federal fines in the last three years: $29,170 (3). Payment denials: 0.
| Date | Type | Amount |
|---|---|---|
| Apr 28, 2025 | Fine | $23,473 |
| Feb 20, 2024 | Fine | $2,279 |
| Jan 22, 2024 | Fine | $3,418 |
Staffing
| Nurse staff hours per resident per day | 4.14 | California median: 4.27 |
| Registered nurse hours per resident per day | 0.26 | California median: 0.52 |
| Nurse staff hours on weekends | 3.77 | California median: 3.85 |
| Nursing staff who left within a year | 35.1% | California median: 36.0% |
About this home
| Beds | 95 |
| Residents per day, average | 85.2 |
| Ownership | For-profit, individual owner |
| Legal business name | Pacific Villa Inc. |
| Chain | Rollins-Nelson Healthcare Management (8 homes) |
| In Medicare/Medicaid since | Mar 13, 1972 |
Questions to ask when you call
- What was corrected after the last inspection?
- How many staff work at night and on weekends?
- Does anyone on staff speak my relative's language?
- May I visit at any time, without an appointment?
Source. Medicare Care Compare (CMS Provider Data), data dated Oct 1, 2026. Open this home on Medicare.gov
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