Sunset Villa Post Acute in Long Beach: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

According to the citation, CDPH made an unannounced visit on June 9, 2026, to investigate a complaint that a resident (Resident 1) fell late on June 5, 2026, and was pronounced dead shortly after midnight. The citation describes Resident 1 as a 64-year-old woman with chronic obstructive pulmonary disease (COPD, a chronic lung disease), heart failure and blood clots. Her POLST form (written medical orders for end-of-life care) said CPR was required if she went into cardiopulmonary distress.

CDPH found that after the fall, Resident 1 declined a hospital transfer and was moved closer to the nursing station, with CNA 1 assigned to watch her. According to the citation, RN 1 found her unresponsive, without a pulse and not breathing at about 12:21 a.m. RN 1 told inspectors he left the room to call a code blue, get the crash cart and call 911. He said he did not ask CNA 1, who was in the room, for help and should have. CDPH found that RN 1 and CNA 1, both CPR certified, did not start CPR right away, and that other CPR-certified staff in the room did not start or help with CPR after the code blue. Inspectors also found the facility did not follow its CPR policy calling for a CPR team on each shift.

According to the citation, paramedics reached the bedside at 12:36 a.m. and continued CPR, and the paramedic run sheet listed the time of death as 12:52 a.m. CDPH determined these failures caused a delay in providing CPR to Resident 1. The department issued a Class A citation with a $25,000 penalty, and the related federal survey cited F678 (cardio-pulmonary resuscitation) at severity J.

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According to the 2567 report, Resident 1 was admitted on October 5, 2024, with a history of falls and a subdural hemorrhage (bleeding on the surface of the brain). She was nonverbal and needed help with transfers and daily care. On the morning of October 7, 2024, CNA 1 found her on the floor of her room, lying on her left side, after an unwitnessed fall. LVN 1, CNA 1 and CNA 2 put her back in bed.

Inspectors found that LVN 1 did not report the fall to Resident 1's physician, so no pain medication could be ordered, and did not do a post-fall assessment to check for injury or pain. According to the report, a physical therapist told LVN 1 that Resident 1 was screaming and guarding (protecting a painful area) her left hip during an evaluation, and LVN 1 did not tell the physician. When the resident's responsible party visited at 10:30 a.m., he found her screaming and grabbing her left hip and asked staff to call 911. Inspectors found LVN 1 also did not tell RNS 1, a nursing supervisor, about the fall.

The 2567 report states paramedics gave Resident 1 intravenous fentanyl (a strong pain medication) before moving her. At a hospital she was found to have a comminuted left intertrochanteric fracture (a hip break with the bone in several pieces) and had surgery. Inspectors found she had unrelieved pain for over two hours after she was found, and a delay in evaluation, treatment and transfer. The federal survey cited F697 (pain management) at severity G.

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According to the citation, CDPH received a complaint about Resident 1's weight loss on July 26, 2024, and made an unannounced visit the same day. The citation describes Resident 1 as an 81-year-old woman admitted in January 2024 with metabolic encephalopathy (a brain condition caused by illness elsewhere in the body) and type 2 diabetes. She had severe cognitive impairment. In March 2024 she had a short hospital stay for a right hip fracture.

CDPH found that Resident 1's weight dropped from 133.8 pounds on March 11, 2024, to 109.5 pounds on April 20, 2024, a loss of 24.3 pounds, or 18.2 percent, in 40 days. According to the citation, staff did not identify that she was eating less from March 16 to March 27, and nursing staff did not tell her physician she was refusing meals until April 1, 16 days later. CDPH found staff also did not follow the facility's unplanned weight loss protocol, the registered dietitian's recommendation to monitor her weight and intake, or her care plan, which called for notifying the physician and dietitian if she refused meals and lost significant weight. The 2567 report states nursing progress notes from March through April 1 had no documentation of her poor intake.

According to the citation, Resident 1 needed a gastrostomy tube (a feeding tube placed into the stomach) on May 6, 2024, and the failures placed her at risk for malnutrition and dehydration. CDPH issued a Class A citation with a $25,000 penalty, and the federal survey cited F692 (nutrition and hydration) at severity G.

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According to the citation, CDPH identified this problem during a standard recertification survey in March 2024. The citation describes Resident 153 as an 81-year-old woman with severe cognitive impairment. On March 8, 2024, at 11:37 p.m., she complained of right hip pain, with moaning and tense, distressed body language. An X-ray reported on March 9 at 12:59 p.m. showed a displaced right hip fracture.

CDPH found the medication record for March 8 showed no pain assessment or pain medication, and the physician's order on March 9 was for Tylenol 325 milligrams, two tablets as needed, for mild pain. According to the citation, she was picked up for a hospital transfer at 10:24 p.m., more than 10 hours after the X-ray result reached the facility. She had hip replacement surgery (arthroplasty) at the hospital. After she returned, the only pain medication ordered from March 14 to 19 was the same Tylenol. On March 20 she told inspectors her pain was the most severe she had ever had.

CDPH determined licensed nurses did not accurately assess and reassess her pain, did not tell her physician the Tylenol was not working or that her pain was unmanageable as her care plan required, and did not follow the facility's pain policy, which called for checks every 30 to 60 minutes for acute pain. The department found she had pain rated 10 out of 10 for almost 24 hours before the transfer, and severe unrelieved pain again from March 14 to 19. CDPH issued a Class A citation with a $25,000 penalty, and the federal survey cited F697 (pain management) at severity G.

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According to the citation, CDPH issued this Class A citation, listed under the category Patient Record, on May 9, 2024. The citation quotes the federal requirement on assisted nutrition and hydration. That rule says a facility must help each resident keep acceptable nutritional status, such as a usual or desirable body weight, offer enough fluids to stay hydrated, and provide a therapeutic diet when there is a nutritional problem and a provider orders one. The citation also quotes state and federal rules on written care plans, on promptly telling the physician about significant changes in a resident's condition, and on food and dietetic services.

In its findings, CDPH determined that the facility failed to ensure that Resident 41's care plan interventions to monitor weight, report significant changes to the physician and observe for signs of malnutrition were followed. The full narrative is in the linked report.

According to the citation, CDPH assessed a $25,000 penalty. The related federal survey, a standard recertification survey in March 2024, cited F692 (nutrition/hydration status maintenance) at severity G.

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According to the 2567 report, inspectors found that while the facility was switching to a new pharmacy provider, three of six sampled residents did not get their medications as their physicians ordered. Resident 1, who was prescribed clonazepam 1 milligram (a controlled medication), missed 23 doses between March 28 and April 14, 2024. Resident 2 missed four doses of a prescribed medication from April 3 to 8, and Resident 3 missed five doses of another prescribed medication from April 9 to 11.

Inspectors found the facility also did not tell the residents' physicians or the medical director about the missed doses, and could not determine how far the medication shortages reached other residents. The report states the missed doses placed the three residents at risk of withdrawal symptoms such as anxiety, insomnia, agitation and muscle aches. On April 24, 2024, inspectors called an Immediate Jeopardy (a finding that noncompliance has caused or is likely to cause serious harm) over Resident 1's missed clonazepam.

According to the 2567 report, the facility's Immediate Jeopardy removal plan included training licensed nurses on the new pharmacy's ordering and delivery process and on what to do when a medication is not available. It also included an investigation by the administrator into Resident 1's missed clonazepam doses and unexpected death, and three-way audits of eight medication carts with both pharmacies. Inspectors verified the plan and removed the Immediate Jeopardy on April 27, 2024. The federal survey cited F760 (significant medication errors) at severity K.

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According to the 2567 report, Resident 1 was admitted on October 5, 2023, from a hospital where he had been treated for aggressive behavior. Hospital records sent to the facility before admission said he had become physically assaultive, aggressive and agitated at another nursing facility and had threatened hospital staff.

Inspectors found that on October 9, 2023, Resident 2, a woman with dementia, asked Resident 1 to get up from her personal chair. Resident 1 became agitated and pushed her to the floor. She had skin tears (wounds where the skin is torn) on both arms and complained of a headache, and a physician ordered staff to watch the top of her head for a bump. LVN 2 told inspectors Resident 2 was "physically shaken up" and that she had not been told Resident 1 had a history of aggressive behavior. According to the report, a social services note a few days later said Resident 2 felt scared and worried about her safety.

The 2567 report states the facility failed to prevent physical abuse of Resident 2. Inspectors found staff did not monitor Resident 1's aggressive behavior, did not develop a care plan with interventions for it, and did not follow the facility's supervision and monitoring policy. The assistant director of nursing told inspectors a baseline care plan for his behaviors should have been created, and confirmed there was none until the day of the incident. The federal survey cited F600 (free from abuse and neglect) at severity G.

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According to the citation, CDPH received a facility-reported incident on September 8, 2022, and made an unannounced visit on September 21. The citation describes Resident 1 as a 91-year-old woman with intact decision-making who walked on her own with a four-wheel walker and needed only supervision. On September 6, 2022, while she was pushing her walker in the dining room, one of the front wheels came off, the walker tilted, and she fell with her right shoulder landing on the walker.

CDPH found she was sent to a hospital, where an X-ray showed a displaced fracture of the right collar bone (clavicle), and her arm was placed in a sling. When she returned, a physical therapist found she could no longer move around as independently as before. She told inspectors she was frustrated because she now had to call for help to do things she used to do herself. According to the citation, her restorative nursing program (care to keep up her strength and function) was put on hold until the fracture healed.

According to the citation, the director of maintenance told inspectors the walker had never been inspected or maintained before the fall, and that the facility knew she had it but never checked the safety of residents' personal walkers. CDPH determined the facility failed to keep the walker in working condition as its own policy on personal equipment required, which led to the fall, the fracture and a decline in her function and mobility. The department issued a Class A citation with a $25,000 penalty.

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