Your report for Pacific Villa, INC
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- CaliforniaLowest tier among peers1,154 rated homes · average 3.2★
- Los Angeles CountyLowest tier among peers368 rated homes · average 2.5★
- United StatesLowest tier among peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point1★−1.8 vs CA avg
- StaffingCan add or remove a star3★−0.1 vs CA avg
- Quality measuresCan add or remove a star3★−1.1 vs CA avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
- Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersCA avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 27% of peersCA avg3.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 9% of peersCA avg4.1★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.96hrsAbove only 21% of peersCA avg4.51Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.22hrsAbove only 2% of peersCA avg0.65Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better39%Above only 44% of peersCA avg38%RN turnover—
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$53,797Above only 16% of peersCA avg$26,970Fines · denials3 · 1
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthFeb 2023 – Dec 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Dec 16, 2025Cycle 1worst D · no actual harm
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Jan 8, 2026
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Jan 8, 2026
Dec 4, 2025Cycle 1worst D · no actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 11, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Dec 11, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 11, 2025
Nov 19, 2025Cycle 1worst E · no actual harm
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrected Dec 11, 2025
- F584Honor 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.Resident RightsD · isolatedCorrected Dec 11, 2025
May 16, 2025Cycle 1worst D · no actual harm
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 11, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 11, 2025
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesD · isolatedCorrected Jun 11, 2025
Apr 28, 2025Cycle 1worst G · actual harm$48,100, payment denial
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Jun 25, 2025
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Jun 25, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected May 21, 2025
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationD · isolatedCorrected Jun 25, 2025
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Jun 25, 2025
Mar 14, 2025Cycle 1worst F · no actual harm
- F814Dispose of garbage and refuse properly.Nutrition and DietaryF · widespreadCorrected Mar 31, 2025
Feb 19, 2025Cycle 1worst D · no actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 12, 2025
Dec 20, 2024Cycle 1worst F · no actual harm
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jan 30, 2025
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Jan 30, 2025
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Jan 30, 2025
- F578Honor 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.Resident RightsE · patternCorrected Jan 30, 2025
- F584Honor 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.Resident RightsD · isolatedCorrected Jan 30, 2025
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningB · patternCorrected Jan 30, 2025
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningE · patternCorrected Jan 30, 2025
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Jan 30, 2025
- F688Provide 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.Quality of Life and CareE · patternCorrected Jan 30, 2025
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesD · isolatedCorrected Jan 30, 2025
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Jan 30, 2025
- F758Implement 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.Pharmacy ServiceD · isolatedCorrected Jan 30, 2025
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Jan 30, 2025
- F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Jan 30, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Jan 30, 2025
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Jan 30, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Jan 30, 2025
Oct 17, 2024Cycle 2worst D · no actual harm
- F626Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.Resident RightsD · isolatedCorrected Nov 7, 2024
Feb 2, 2024Cycle 2worst D · no actual harm$2,279
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Feb 20, 2024
Feb 1, 2024Cycle 2worst D · no actual harm$2,279
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Feb 12, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Feb 12, 2024
Jan 5, 2024Cycle 2worst F · no actual harm$3,418
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Feb 1, 2024
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Feb 1, 2024
- F685Assist a resident in gaining access to vision and hearing services.Quality of Life and CareD · isolatedCorrected Feb 1, 2024
- F688Provide 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.Quality of Life and CareE · patternCorrected Feb 1, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Feb 1, 2024
- F693Ensure 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.Quality of Life and CareD · isolatedCorrected Feb 1, 2024
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected Feb 1, 2024
- F699Provide care or services that was trauma informed and/or culturally competent.Quality of Life and CareD · isolatedCorrected Feb 1, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Feb 1, 2024
- F758Implement 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.Pharmacy ServiceD · isolatedCorrected Feb 1, 2024
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Feb 1, 2024
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceE · patternCorrected Feb 1, 2024
- F761Ensure 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.Pharmacy ServiceE · patternCorrected Feb 1, 2024
- F790Provide routine and 24-hour emergency dental care for each resident.Quality of Life and CareE · patternCorrected Feb 1, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Feb 1, 2024
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Feb 1, 2024
- F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalD · isolatedCorrected Feb 1, 2024
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Feb 1, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Feb 1, 2024
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Feb 1, 2024
Dec 11, 2023Cycle 3worst D · no actual harm
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Jan 17, 2024
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Jan 17, 2024
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Jan 17, 2024
- F573Let each resident or the resident's legal representative access or purchase copies of all the resident's records.Resident RightsD · isolatedCorrected Jan 17, 2024
- F555Honor the resident's right to choose his or her attending physician.Resident RightsD · isolatedCorrected Jan 17, 2024
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Jan 17, 2024
Mar 28, 2023Cycle 3worst E · no actual harm
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected May 16, 2023
Feb 16, 2023Cycle 3worst E · no actual harm
- F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningD · isolatedCorrected Mar 9, 2023
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Mar 9, 2023
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Mar 9, 2023
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Mar 9, 2023
- F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and CareD · isolatedCorrected Mar 9, 2023
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Mar 9, 2023
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Mar 9, 2023
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Mar 9, 2023
- F693Ensure 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.Quality of Life and CareD · isolatedCorrected Mar 9, 2023
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Mar 9, 2023
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Mar 9, 2023
- F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Mar 9, 2023
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Mar 9, 2023
- F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Nutrition and DietaryE · patternCorrected Mar 9, 2023
- Assure that each residentâs assessment is updated at least once every 3 months.Resident Assessment and Care PlanningD · isolatedCorrected Mar 9, 2023
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Mar 9, 2023
- F908Keep all essential equipment working safely.EnvironmentalE · patternCorrected Mar 9, 2023
- F888Ensure staff are vaccinated for COVID-19Infection ControlE · patternCorrected Mar 9, 2023
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Mar 9, 2023
- F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Resident RightsD · isolatedCorrected Mar 9, 2023
- F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Resident RightsD · isolatedCorrected Mar 9, 2023
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Mar 9, 2023
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Mar 9, 2023
- F584Honor 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.Resident RightsE · patternCorrected Mar 9, 2023
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.96hrs
- Registered nursesRN hours only0.22hrs
- Licensed practical nursesLPN hours0.96hrs
- Nurse aidesCNA hours2.78hrs
- Weekend nursingAll staff on Saturdays and Sundays3.64hrs
- California average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better39%Above only 44% of peersCA avg 38%
- RN turnoverRegistered nurses only—Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy95 certified beds · ~87 residents a day91%Above only 49% of peersCA avg 88%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $53,797In fines
- 3Fines
- 1Payment denial
- $26,970CA avg in fines
Actions on record
- Apr 28, 2025Civil money penalty$48,100
- Apr 28, 2025Denial of payment for new admissionsfrom May 27, 2025
- Feb 20, 2024Civil money penalty$2,279
- Jan 22, 2024Civil money penalty$3,418
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Individual
- Chain
- Rollins-Nelson Healthcare Management10 facilities in the chain2.2★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Pacific Villa INC
- William Nelson
- Vicki Rollins
- Pacific Villa INC
- Vicki Rollins
- Pacific Villa INC
- Trevor Anderson
- Evangeline Estavillo
- Ronald Philipp
- Vicki Rollins
- William Nelson
- Vicki Rollins
- William Nelson
- Vicki Rollins
- William Nelson
- Vicki Rollins
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 056313 · 3501 CEDAR AVENUE, LONG BEACH, CA, 90807.
- Percentiles compare this facility with every rated nursing home in California and Los Angeles County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









