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Nursing HomeMedicaid Investigative

Pacific Villa, INC

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

3501 Cedar Avenue, Memorial Heights · Long Beach, CA 9080795 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
3.6/5

based on 16 Google reviews

5
4
3
2
1
Pacific Villa, INC Nursing Home in Long Beach, CA — Street View
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5/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Abuse citation on record
  • Low overall rating (1/5 stars)
  • Above-median deficiencies (33 vs median 13.0)

Bottom 25% in CA · Critically understaffed (RN) · Worst in ROLLINS-NELSON HEALTHCARE MANAGEMENT chain · $53,797 in fines · Abuse citation

Source: Medicare data

What this means for your family

While some staff members are noted for being kind and the facility is clean, there are alarming patterns of administrative unresponsiveness and serious medication safety concerns. If you choose this facility, you must implement a rigorous system for checking medication logs and ensure you have a direct, working line of communication with the administration.

Google Reviews

Google Reviews

16 reviews on Google
Families should approach this facility with significant caution due to serious allegations regarding medication errors, lack of responsiveness from administration, and unprofessional conduct. While some reviewers praise the cleanliness and specific nursing staff, there are recurring reports of poor communication, difficulty reaching social workers, and issues with patient advocacy.

Quality Themes

Tap a score for details
Food5.0Staff3.0Clean8.0Activities6.0Meds1.0MemoryN/AComms1.0ValueN/A

Strengths

  • Clean and well-maintained facility
  • Attentive and compassionate nursing staff
  • Engaging daily activities like chair exercises

Concerns

  • Poor administrative responsiveness and communication (mentioned by 3 reviewers)
  • Issues with medication management and safety (mentioned by 2 reviewers)
  • Theft or loss of resident belongings (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'17(2)'19(2)'22(5)'24(1)'26(1)

Distribution · 18 analyzed

5
8
4
2
3
4
2
0
1
4

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1I've read that the facility is very clean and well-maintained; could you tell me more about your housekeeping schedule and how you keep the resident areas tidy?
  • 2We've heard great things about your daily activities like chair exercises; what other types of engaging programs do you offer to keep residents active?
  • 3Could you walk me through your specific protocols for medication administration and how you ensure there are no errors in the process?
  • 4How does the nursing team communicate important medical updates or changes in condition to family members to ensure we are always in the loop?
  • 5What steps are in place to ensure that residents' personal belongings and valuables are kept secure and accounted for?
  • 6In the event of a medical emergency during the night, what is the immediate procedure for notifying the family and coordinating care?

Personalized based on this facility's data


Key Review Excerpts

The nurses and caregivers are attentive, patient, and genuinely caring, creating a safe and supportive environment for residents and families.

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

I left two messages on social workers ext. finally got to talk to Nancy the Social worker. I said I've left two messages on her ext nd she said she doesn't even have voice mail set up yet

Family member seeking transfer · 2025☆☆☆☆

They put a false statement in my sister's chart saying she struck at nurses, so she was rejected by another nursing home;

Family member · 2023☆☆☆☆
Source: 16 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.22hrs
29%
Registered nurses for medical care
Total Nursing
4.08hrs
100%
All nurses + aides combined
Staff Turnover
37%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 16 measures

Medicare Rating
3/ 5
Better Than Avg

10

measures

Worse Than Avg

4

measures

Mixed Results

2

measures

Long-Stay Residents
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility78.0%
Worse than Avg
Here
78.0%
US
15.4%
CA
11.6%
Los angeles
11.4%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility31.5%
Worse than Avg
Here
31.5%
US
19.5%
CA
13.7%
Los angeles
10.8%
😔

Residents with depression symptoms

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
12.1%
CA
7.0%
Los angeles
8.7%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility20.0%
Worse than Avg
Here
20.0%
US
14.4%
CA
10.4%
Los angeles
12.5%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility12.1%
Mixed vs Avgs
Here
12.1%
US
19.4%
CA
10.7%
Los angeles
9.7%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility16.4%
Worse than Avg
Here
16.4%
US
15.3%
CA
10.5%
Los angeles
9.5%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
79.7%
CA
93.2%
Los angeles
92.5%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility96.3%
Better than Avg
Here
96.3%
US
81.8%
CA
94.2%
Los angeles
94.5%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

25deficiencies
4penalties
Well above state avg (15.4)
32 complaint-triggered
$53,797 in fines

Pacific Villa shows concerning patterns of repeated deficiencies, particularly in abuse protection and medication management, with families filing numerous complaints that triggered inspections. The facility has struggled with protecting residents from abuse, proper medication handling, infection control, and maintaining safe living conditions. While all violations show correction dates, the persistence of similar issues across multiple surveys suggests ongoing systemic problems that families should carefully evaluate before considering this facility.

Feb 27, 2026Routine
28
0880Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0345Potential for harm · WidespreadCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0521Potential for harm · WidespreadCorrected

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0790Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide routine and 24-hour emergency dental care for each resident.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0325Potential for harm · PatternCorrected

Smoke Deficiencies

Have properly installed hallway dispensers for alcohol-based hand rub.

0881Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

0605Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

0607Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0676Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

0679Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

0685Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

0697Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

0726Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

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.

0757Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

0321Potential for harm · IsolatedCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0351Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install an approved automatic sprinkler system.

0741Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

0923Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

0346Minimal · WidespreadCorrected

Smoke Deficiencies

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

0354Minimal · WidespreadCorrected

Smoke Deficiencies

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

0712Minimal · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0920Minimal · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Dec 16, 2025Complaint
2
0580Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Dec 4, 2025Complaint
3
0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Nov 19, 2025Complaint
2
0921Potential for harm · PatternCorrected

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

0584Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

May 16, 2025Complaint
3
0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0726Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

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.

Apr 28, 2025Complaint
5
0600Actual harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0867Potential for harm · IsolatedCorrected

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Federal Penalties

Fine

Apr 28, 2025

$36,075

Payment Denial

Apr 28, 2025

29-day denial

Fine

Feb 20, 2024

$2,279

Fine

Jan 22, 2024

$3,418

Ownership & Operations

Who Operates This Facility

Owner / Operator

Pacific Villa, INC

Organization Type

for profit

Chain Affiliation

Chain Name

Rollins-Nelson Healthcare Management

Chain Size

10 facilities nationwide

Chain avg rating: 2.1/5 · Rank 10 of 10 (Worst)

Ownership & Management

Owners

Pacific Villa INC

Owner · Organization

Nelson, William

Owner

Rollins, Vicki

Owner

Pacific Villa INC

Owner (parent company) · Organization

Nelson, William

Owner (parent company)

Rollins, Vicki

Owner (parent company)

Key personnel

Rollins, VickiAdp of the SnfThe Palms Real Estate, LLC5% or Greater Mortgage InterestNelson, William5% or Greater Mortgage InterestRollins, Vicki5% or Greater Mortgage InterestNelson, William5% or Greater Security Interest
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

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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