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Assisted Living Investigative

Knolls West Assisted Living

Reviewer concerns include severe neglect regarding hygiene and diaper changes (mentioned by 6 reviewers) — investigate before committing.

16890 Green Tree Blvd., Victorville, CA 9239564 bedsLicensed & Active
Google rating
2.3/5

based on 63 Google reviews

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Knolls West Assisted Living Assisted Living in Victorville, CA — Street View
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What this means for your family

This facility presents significant risks regarding patient hygiene and medication safety. While some families report wonderful experiences with specific staff members, the recurring pattern of neglect and poor communication from management is a major red flag that requires immediate investigation if you consider this facility.

Google Reviews

Google Reviews

63 reviews on Google
Families should exercise extreme caution, as a significant number of reviews report severe neglect, including patients being left in soiled diapers for hours and delayed medication administration. While some long-term residents and their families praise the kindness of specific nurses and the cleanliness of the facility, these positive experiences are overshadowed by frequent allegations of medical errors, theft of personal belongings, and poor communication from management.

Quality Themes

Tap a score for details
Food1.0Staff2.0Clean4.0ActivitiesN/AMeds1.0MemoryN/AComms1.0ValueN/A

Strengths

  • Kindness of specific nursing and CNA staff
  • Cleanliness of the physical facility
  • Effective physical therapy services

Concerns

  • Severe neglect regarding hygiene and diaper changes (mentioned by 6 reviewers)
  • Delayed medication administration and slow response to call lights (mentioned by 5 reviewers)
  • Theft or loss of patient belongings and clothing (mentioned by 3 reviewers)
  • Poor communication from administration and management (mentioned by 4 reviewers)
  • Inadequate staffing levels leading to patient safety risks (mentioned by 4 reviewers)

Rating Trends

Tap a year to see what changed

234'16(3)'18(5)'20(2)'22(14)'24(6)'26(4)

Distribution · 65 analyzed

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4
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0
1
42

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1We've heard wonderful things about the kindness of your nursing and CNA staff; how do you ensure that level of care remains consistent across all shifts?
  • 2Could you walk us through the specific protocols you have in place for timely medication administration and responding to call lights?
  • 3How does the team manage personal hygiene routines and regular incontinence care to ensure every resident stays clean and comfortable?
  • 4What steps are taken to track resident belongings and clothing to prevent any items from being lost or misplaced?
  • 5We'd love to hear more about the dining experience and how the meal service is structured for the residents.
  • 6In the event of a medical emergency after hours, what is the immediate process for getting care to a resident?

Personalized based on this facility's data


Key Review Excerpts

The care from the CNA’s, nurses, housekeeping, dietitians, administrators and everyone in between is top notch. They became like family during my husband’s stay there.

Long-term resident's family · 2026★★★★★

My mom was admitted and not given her medications for 24 hours. When ringing for a nurse the wait time was usually over 1 hour which usually left her soiling herself.

Resident's family · 2024☆☆☆☆

They leave them in dirty diapers. When it's time for their medication, they are never given it on time. The food they provide is really unedible.

Resident's family · 2025★★★★★
Source: 63 Google reviews

State Inspection History

State Inspections

Source: CA Community Care Licensing Division

11total
1 Type A— immediate health risk
3 Type B— non-compliance
Clean record— no deficiencies found
Feb 23, 2026Complaint
Clean

COMPLAINT INVESTIGATION REPORT

Dec 17, 2025Complaint
Clean

This report details an investigation into a complaint alleging that staff did not ensure residents were fed. The investigation found no evidence to corroborate the allegation, resulting in an 'Unsubstantiated' finding for the complaint.

Aug 8, 2025Inspection
Clean

The facility underwent a required comprehensive annual inspection on August 8, 2025. The inspection covered physical plant, food service, care, and record review. No deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

Dec 9, 2024Complaint
Clean

This report details the investigation of a complaint received on 12/04/2024. The investigation found that both allegations—regarding meal service timeliness and medication dispensing—were unfounded. The complaint has therefore been dismissed by the agency.

Aug 22, 2024Inspection
Clean

The facility underwent a required comprehensive annual inspection. Overall, the facility was found to be clean, in good repair, and operating in safe conditions. However, one technical violation was cited regarding the outdated format of the Emergency Disaster Plan.

Oct 27, 2023Other
Clean

The facility underwent an unannounced case management visit on October 27, 2023. The Licensing Program Analyst conducted an interview, reviewed records, and walked through the residents' room. No deficiencies were observed during this visit.

Jul 31, 2023Inspection
Clean

The inspection identified three deficiencies, including one Type A citation related to staff criminal record clearances, which poses an immediate risk. Additionally, there are two Type B deficiencies concerning the administrator's certification status and the failure to process transfer clearances for staff members. The facility was noted to be clean and generally safe, but these administrative and staffing compliance issues require immediate attention.

Nov 4, 2022Complaint
Clean

COMPLAINT INVESTIGATION REPORT

Ownership & Operations

Who Operates This Facility

Owner / Operator

Knolls West Assisted Living LLC

Administrator

TERRONSAY WHALEY

Source: State licensing data

Contact

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References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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