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Avalon Villa Care Center at a glance: owner, beds and ratings
* California separately requires at least 3.5 direct care service hours per patient day, counted under state rules, so the two numbers are not measured the same way.
Records: Cal Health Find ↗ · Medicare Care Compare ↗
Avalon Villa Care Center citations and inspection findings
Newest first. State citations come from CDPH; federal deficiencies come from the CMS-2567 inspection report CDPH writes for Medicare. Every row links to the government record.
| Date | Source | Finding | Record |
|---|---|---|---|
| February 19, 2026 | State (CDPH) | Class B citation (Patient Care), penalty $3,150 | Government record (CDPH) ↗ |
| January 5, 2026 | Federal (CMS-2567), Certification | F688 – Increase/Prevent Decrease in ROM/Mobility, severity G (actual harm, one or a few residents) Read what inspectors found ↓ | Government record (CDPH) ↗ |
| August 5, 2025 | Federal (CMS-2567), Complaint | F609 – Reporting of Alleged Violations, severity D (no actual harm, potential for more than minimal harm, isolated) Abuse | Government record (CDPH) ↗ |
| March 14, 2025 | State (CDPH) | Class B citation (Patient Care), penalty $3,000 | Government record (CDPH) ↗ |
| March 14, 2025 | State (CDPH) | Class B citation (Patient Care), penalty $3,000 | Government record (CDPH) ↗ |
| February 19, 2025 | State (CDPH) | Class B citation (Patient Care), penalty $3,000 | Government record (CDPH) ↗ |
| February 19, 2025 | State (CDPH) | Class B citation (Patient Care), penalty $3,000 | Government record (CDPH) ↗ |
| January 27, 2025 | Federal (CMS-2567), Certification | F689 – Free of Accident Hazards/Supervision/Devices, severity J (immediate jeopardy, one or a few residents) F609 – Reporting of Alleged Violations, severity D (no actual harm, potential for more than minimal harm, isolated) AbuseFalls / supervision › Read what inspectors found ↓ | Government record (CDPH) ↗ |
| November 19, 2024 | State (CDPH) | Administrative Penalty (DHPPD: 2 – 11 Days), penalty $25,000 | Government record (CDPH) ↗ |
| February 27, 2024 | State (CDPH) | Class B Trebled citation (Abuse/Facility Not Self Reported), penalty $9,000 Abuse | Government record (CDPH) ↗ |
| February 27, 2024 | State (CDPH) | Class A citation (Patient Care), penalty $25,000 Read what inspectors found ↓ | Government record (CDPH) ↗ |
| January 24, 2024 | Federal (CMS-2567), Complaint | F609 – Reporting of Alleged Violations, severity D (no actual harm, potential for more than minimal harm, isolated) F656 – Develop/Implement Comprehensive Care Plan, severity G (actual harm, one or a few residents) Abuse Read what inspectors found ↓ | Government record (CDPH) ↗ |
Show 7 older findings
| Date | Source | Finding | Record |
|---|---|---|---|
| November 30, 2023 | Federal (CMS-2567), Complaint | F600 – Free from Abuse and Neglect, severity D (no actual harm, potential for more than minimal harm, isolated) Abuse | Government record (CDPH) ↗ |
| October 30, 2023 | Federal (CMS-2567), Complaint | F609 – Reporting of Alleged Violations, severity D (no actual harm, potential for more than minimal harm, isolated) Abuse | Government record (CDPH) ↗ |
| October 19, 2023 | Federal (CMS-2567), Complaint | F600 – Free from Abuse and Neglect, severity D (no actual harm, potential for more than minimal harm, isolated) Abuse | Government record (CDPH) ↗ |
| September 18, 2023 | State (CDPH) | Class B citation (Abuse/Facility Not Self Reported), penalty $3,000 Abuse | Government record (CDPH) ↗ |
| August 3, 2023 | Federal (CMS-2567), Complaint | F609 – Reporting of Alleged Violations, severity D (no actual harm, potential for more than minimal harm, isolated) F610 – Investigate/Prevent/Correct Alleged Violation, severity D (no actual harm, potential for more than minimal harm, isolated) Abuse | Government record (CDPH) ↗ |
| March 17, 2023 | State (CDPH) | Class A citation (Patient Rights), penalty $25,000 Read what inspectors found ↓ | Government record (CDPH) ↗ |
| March 17, 2023 | State (CDPH) | Class B citation (Abuse/Facility Not Self Reported), penalty $3,000 Abuse | Government record (CDPH) ↗ |
What inspectors found at Avalon Villa Care Center
Tap a finding to read the summary. Each one is written from the government report linked under it.
January 2026: F688 (severity G) after a resident's ankle range of motion declined when ordered braces were not applied
The 2567 report states the facility did not provide services to maintain or improve range of motion (how far a joint can move) and mobility for five of six sampled residents. According to the report, Resident 37 had a stroke, paraplegia (loss of movement in the legs) and contractures (stiff, shortened joints) in both hands and the right thigh. When his physical therapy ended on November 11, 2025, the physician ordered restorative nursing aides to give passive range of motion exercises to both arms and legs and to apply hand splints and leg braces for two hours, three times a week.
Inspectors found the restorative flow sheets for November 2025 through January 2026 had no task for the leg braces and no record they were applied. Resident 37 told inspectors the aides put boots on his feet once a few weeks earlier and never reapplied them. The 2567 report states the limitation of his ankles into plantarflexion (toes pointed down) went from 12-22 degrees on the left and 10-12 degrees on the right at therapy discharge to 39-58 and 40-59 degrees on January 8, 2026.
Inspectors found therapists also skipped joint measurements in evaluations of four other residents, and two of them went months without ordered exercises. The facility was cited under F688 (range of motion and mobility) at severity G.
January 2025: F689 (severity J) and F609 (severity D) after a resident left the facility unnoticed twice and had not been found
The 2567 report states Resident 118, who had Alzheimer's disease and moderately impaired thinking, was assessed as high risk for wandering and elopement (leaving without staff knowing). According to the report, he left the facility unsupervised on October 13, 2024, and, after being readmitted, left again on November 24, 2024. As of January 29, 2025, 66 days later, he had not been found.
Inspectors found that after the first elopement staff did not create a care plan for his elopement risk, did not do 72-hour monitoring on readmission and placed him in a room near the lobby exit. Nurses told inspectors his risk was shared only within his own nursing station and aides were told verbally to "keep an eye" on him, with no set checks and no documentation. Inspectors also found other failures, including unsecured lighters and a missing fall mat.
The 2567 report states a registered nurse said she was told not to alert authorities after the first elopement, and the administrator told inspectors neither elopement was reported to CDPH or the ombudsman. Inspectors called an immediate jeopardy on January 29, 2025, and removed it on January 31 after verifying the facility's removal plan. The facility was cited under F689 (accident hazards and supervision) at severity J and F609 (reporting of alleged violations) at severity D.
February 2024: Class A citation, F656 (severity G) and F609 (severity D) after refused seizure medication doses and a fall with an ankle fracture
According to the citation, Resident 2, a 78-year-old woman with epilepsy (a brain condition that causes seizures), had a physician's order for the seizure medication levetiracetam twice a day, and her care plan called for staff to give it and watch for seizure activity every shift. CDPH found her medication record showed she refused the 9 a.m. dose every day from January 1 to January 7, 2024. A licensed vocational nurse told inspectors she did not tell the physician about the refusals and that the resident was not monitored for seizure activity.
According to the citation, on January 8, 2024, a registered nurse found Resident 2 on the bathroom floor near the toilet, and the resident then had a seizure lasting about 10 to 15 seconds. She was admitted to an acute care hospital, where an X-ray showed a fracture dislocation of the right ankle. CDPH found the fall led to a decline in her mobility and daily self-care. CDPH issued a Class A citation with a $25,000 penalty.
The 2567 report states the same events were cited under F656 (care plans) at severity G. The report also cites F609 (reporting of alleged violations) at severity D. Inspectors found that when Resident 1 was heard screaming "stop, don't hit me" during a diaper change early on January 8, 2024, staff did not report the abuse allegation to the administrator within two hours.
March 2023: Class A citation after a nursing assistant grabbed a resident by the neck
According to the citation, Resident 1, a 52-year-old woman who used a wheelchair and whose thinking was intact, said that on the night of December 1, 2022, she argued with CNA 1 and that CNA 1 later grabbed her neck as she tried to enter the bathroom in her room. Two other aides told inspectors they saw CNA 1 yelling at the resident, and one said the resident was crying and appeared frightened. The administrator told CDPH the facility's own investigation found CNA 1 did verbally and physically assault the resident.
CDPH found that RN 1 was told of the commotion but did not go to the room right away, did not assess the resident for injuries, and did not report the incident to the director of nursing, the administrator or law enforcement. According to the citation, CNA 1 was not sent home and finished her shift. A change of condition note was not written until the next morning, when the resident reported neck pain. CNA 1 was terminated on December 5, 2022. Inspectors found night shift staff did not receive the abuse prevention training given after the incident.
The department determined the abuse caused Resident 1 pain in her neck, made her cry and made her fear for her safety. CDPH issued a Class A citation for patient rights violations with a $25,000 penalty.
Complaints against Avalon Villa Care Center
| Year | Intakes | Complaints | Facility-reported incidents | Substantiated (at least one allegation) |
|---|---|---|---|---|
| 2023 | 29 | 22 | 7 | 16 |
| 2024 | 21 | 9 | 12 | 12 |
| 2025 | 50 | 39 | 11 | 18 |
| 2026 | 28 | 20 | 8 | 4 |
Cal Health Find lists 128 complaint and facility-reported incident intakes for this facility from 2023 through October 30, 2026. CDPH substantiated at least one allegation in 50 of them. 43 intakes involved an allegation in CDPH’s abuse category, and 19 of those had an abuse allegation substantiated. An intake can contain several allegations; “unsubstantiated” means CDPH did not find enough evidence, not that nothing happened.
Sexual abuse reports at Avalon Villa Care Center
Cal Health Find lists 3 intakes for Avalon Villa Care Center from 2023 through October 30, 2026 that included an allegation CDPH classified as sexual abuse (3 from complaints and 0 reported by the facility itself). CDPH substantiated a sexual abuse allegation in 0 of them. Federal rules require a nursing home to report an abuse allegation to the state within two hours, so a facility-reported incident means staff raised the allegation, not that it was proven. “Unsubstantiated” means CDPH did not find enough evidence; it does not mean nothing happened.
| Year | Intakes with a sexual abuse allegation | Substantiated |
|---|---|---|
| 2023 | 1 | 0 |
| 2025 | 2 | 0 |
Warning signs include bruising or bleeding in the genital area or inner thighs, a new genital infection, torn or stained underclothing, and a resident who suddenly fears a particular staff member or resists being bathed or changed. If you suspect sexual abuse, call 911 or local police first, ask that the resident not be bathed before a medical exam, and then report it to CDPH and the long-term care ombudsman. Sexual abuse reports at Los Angeles County nursing homes →
Staffing at Avalon Villa Care Center
Payroll records Avalon Villa Care Center filed with the federal Centers for Medicare & Medicaid Services (CMS) for April through June 2026 show an average of 3.93 nursing hours per resident per day, counting registered nurses (RNs), licensed vocational nurses and nurse aides. The California average CMS published for the same period is 4.54, and the Los Angeles County median is 4.32. RN time averaged 0.34 hours per resident per day (California average 0.68). Staffing averaged 3.61 hours on weekends and 4.06 on weekdays.
CMS reports nursing staff turnover of 51.0% at this facility (California average 36.6%) and RN turnover of 83.3% (California average 37.8%).
California requires most skilled nursing facilities to provide at least 3.5 direct care hours per patient day (Health and Safety Code section 1276.65). Counting the RN, LVN and nurse aide hours in the same payroll data, Avalon Villa Care Center was below 3.5 on 17 of 91 days. This is our calculation from CMS data, not a CDPH finding: CDPH counts some staff differently (for example psychiatric technicians in special treatment programs) and can grant waivers.
| Avalon Villa Care Center | LA County median | California average | |
|---|---|---|---|
| Total nursing hours per resident per day | 3.93 | 4.32 | 4.54 |
| RN hours per resident per day | 0.34 | 0.46 | 0.68 |
| Weekend nursing hours per resident per day | 3.61 | 3.89 | 4.10 |
| Nursing staff turnover | 51.0% | 34.1% | 36.6% |
Compare staffing, profits and fines across Los Angeles County nursing homes →
Who owns Avalon Villa Care Center
The owners and operators below are listed for Avalon Villa Care Center in the federal CMS nursing home ownership file (data as of October 1, 2026). CMS requires each Medicare-certified nursing home to report anyone with a 5% or greater ownership stake and anyone with operational or managerial control.
| Owner or operator | Role | Share | Since |
|---|---|---|---|
| Harry Jacobs | 5% or greater direct ownership | 100% | June 9, 2015 |
| Harry Jacobs | Operational or managerial control | – | June 9, 2015 |
In its annual report to the California Department of Health Care Access and Information (HCAI) for the year ending December 31, 2025, the facility listed $2.3 million in payments to related companies (businesses that share owners or management with the facility): $1.2 million to 12029 S Avalon Blvd LLC for lease expense – building; $1.1 million to Grandview Administrative Services for adm – management fees. Payments to related companies are legal; California requires nursing homes to disclose them.
Avalon Villa Care Center finances
Avalon Villa Care Center reported $20.4 million in health care revenue and net income of $1.9 million for the year ending December 31, 2025, a margin of 9.2%, in its annual financial report to HCAI (as submitted; HCAI has not finished reviewing it). The median operating margin that year was 5.9% for Los Angeles County nursing homes and 6.1% statewide. Medi-Cal paid for 71% of resident days. Salaries for RNs, LVNs and nurse aides came to $4.9 million.
| Year | Revenue | Net income | Margin | Occupancy | Medi-Cal days |
|---|---|---|---|---|---|
| 2023 | $18.0 million | $1.4 million | 8.0% | 92% | – |
| 2024 | $18.0 million | $1.5 million | 8.1% | 90% | 69% |
| 2025 | $20.4 million | $1.9 million | 9.2% | 91% | 71% |
Federal fines and penalties: Avalon Villa Care Center
CMS lists Avalon Villa Care Center as a candidate for its Special Focus Facility program. CMS created the program for nursing homes with a history of serious quality problems; candidates are facilities whose inspection record qualifies them, and states choose which ones enter the program for closer oversight.
CMS lists 2 federal fines totaling $86,782 and 2 Medicare payment denials for Avalon Villa Care Center in the roughly three years its penalty file covers.
| Date | Penalty | Amount or length |
|---|---|---|
| November 21, 2025 | Fine | $45,325 |
| November 21, 2025 | Payment denial | 5 days |
| January 31, 2025 | Fine | $41,457 |
| January 31, 2025 | Payment denial | 24 days |
Avalon Villa Care Center lawsuits and criminal cases
We searched California Attorney General and Los Angeles County District Attorney announcements and news coverage for Avalon Villa Care Center and its licensee and found no public criminal case or civil lawsuit we could tie to this facility as of October 30, 2026. Many civil cases settle quietly or are not covered by the press, so this is not a complete court search.
What this record means for your family
California uses classes for state citations. Under Health and Safety Code section 1424 ↗, a Class AA citation is a Class A violation that CDPH determined was a direct proximate cause of a resident’s death. A Class A citation means CDPH found an imminent danger, or a substantial probability, that death or serious physical harm would result. Class B covers violations with a direct or immediate relationship to residents’ health, safety or security.
Federal deficiencies carry a letter from A to L. G, H and I mean inspectors found actual harm to residents; J, K and L mean immediate jeopardy, the most serious level. F600 is the federal rule that residents be free from abuse and neglect; F609 and F610 cover reporting and investigating allegations; F689 covers accidents and supervision; F686 covers pressure injuries.
Warning signs worth asking about: unexplained bruises or fractures, new bed sores, sudden weight loss or dehydration, a resident who becomes fearful or withdrawn around certain staff, and calls that go unanswered.
What to do now
- If someone is in danger, call 911.
- File a complaint with CDPH about Avalon Villa Care Center: CDPH complaint form ↗
- Contact the long-term care ombudsman, the state-funded advocate for nursing home residents: California Long-Term Care Ombudsman ↗
- Ask the facility in writing for a copy of the resident’s chart, and write down dates, names of staff on shift, and photos of any injury.
- Talk to a Los Angeles nursing home abuse lawyer →
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Questions families ask
Has Avalon Villa Care Center been cited by the State of California?
Cal Health Find lists 12 state citations for Avalon Villa Care Center since 2023, including 0 Class AA and 2 Class A. Each one is listed in the timeline above with a link to the CDPH record.
How many complaints have been filed against Avalon Villa Care Center?
From 2023 through October 30, 2026, Cal Health Find lists 128 complaint and facility-reported incident intakes, and CDPH substantiated at least one allegation in 50 of them.
Does Medicare flag Avalon Villa Care Center for abuse?
As of our data date, Medicare Care Compare does not show its abuse icon for Avalon Villa Care Center. The icon is only one signal; read the citations above.
Have there been sexual abuse reports at Avalon Villa Care Center?
Cal Health Find lists 3 complaint or facility-reported incident intakes at Avalon Villa Care Center since 2023 that included an allegation CDPH classified as sexual abuse, and CDPH substantiated 0. The section above breaks them down by year.
Where can I read reviews and complaints about Avalon Villa Care Center?
Online reviews are opinions. The official record is the state and federal inspection file: this page summarizes it and links each citation, complaint outcome and inspection report on Cal Health Find and Medicare Care Compare, so you can read the source yourself.
How many beds does Avalon Villa Care Center have?
Avalon Villa Care Center is licensed by CDPH for 131 beds and has a CMS overall rating of 1 out of 5 stars.
Who owns or operates Avalon Villa Care Center?
CDPH lists the licensee as AVALON VILLA HEALTH CARE, LLC. CMS does not list a chain for this facility. According to the CMS ownership file, Jacobs, Harry holds 100% as a direct owner. The full list of owners and operators CMS reports is in the ownership section of this page.
How many nursing hours does Avalon Villa Care Center provide per resident?
Payroll data the facility filed with CMS for April through June 2026 show 3.93 total nursing hours per resident per day, including 0.34 RN hours. The California average is 4.54.
My parent was hurt at Avalon Villa Care Center. What should I do?
Get medical care first, then report it to CDPH and the long-term care ombudsman, ask for the chart in writing and keep notes and photos. For a free, confidential review of a possible case, call Beverly Law at (310) 552-6959.
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Other nursing homes near Avalon Villa Care Center
| Facility | City | Distance | CMS stars | Class AA/A | Federal G–L |
|---|---|---|---|---|---|
| View Heights Convalescent Hospital | Los Angeles | 0.3 mi | 2/5 | 1 | 2 |
| Lighthouse Healthcare Center | Los Angeles | 2.0 mi | 1/5 | 2 | 3 |
| Rosecrans Care Center | Gardena | 2.3 mi | 3/5 | 0 | 2 |
| Gardena Convalescent Center | Gardena | 2.4 mi | 3/5 | 1 | 0 |
| Kei-Ai South Bay Healthcare Center | Gardena | 2.5 mi | 2/5 | 2 | 2 |
| Memorial Hospital of Gardena D/P SNF | Gardena | 2.7 mi | 4/5 | 0 | 1 |
Methodology and sources
We pulled this facility’s complaints, state enforcement actions and survey deficiencies from Cal Health Find for 2023 through October 30, 2026, downloaded the CDPH citation notices and CMS-2567 reports behind every Class AA or A citation and every federal deficiency at level G or higher, and wrote the summaries above from those documents. Facility details come from the CDPH licensing file and the CMS Provider Data Catalog. Residents are described only as the government documents describe them. See the methodology page to report an error; we review correction requests within five business days.
Sources
- Cal Health Find – Avalon Villa Care Center
- Medicare Care Compare – Avalon Villa Care Center
- CMS – Payroll-Based Journal Daily Nurse Staffing (2026 Q2)
- CMS – Nursing home Provider Information (staffing, turnover)
- CMS – Nursing home Ownership
- CMS – Nursing home Penalties
- HCAI – Long-Term Care Facility Financial Data
- CDPH – State Enforcement Actions (open data)
- CMS Provider Data Catalog – Nursing homes
Important: This page reports findings from public records of the California Department of Public Health and the Centers for Medicare & Medicaid Services. A citation or deficiency is a regulatory finding by a government agency; it is not a court judgment and not proof of civil or criminal liability. Criminal defendants are presumed innocent unless proven guilty. Lawsuit allegations are claims, not findings. This page is general information, not legal advice, and reading it does not create an attorney-client relationship with Beverly Law. Attorney advertising. Prior results do not guarantee a similar outcome. Data as of: October 30, 2026. Methodology and corrections.
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