Pacific Villa, INC
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 16 Google reviews

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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
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 detailsStrengths
- 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
Distribution · 18 analyzed
How They Respond to Reviews
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.”
“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”
“They put a false statement in my sister's chart saying she struck at nurses, so she was rejected by another nursing home;”
Staffing
Staffing Hours
per resident/day · Medicare 2026Both 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
10
measures
4
measures
2
measures
Residents on antipsychotic medication
Residents on anti-anxiety or sleep medication
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents needing more daily help over time
Residents whose bladder or bowel control got worse
Residents whose walking got worse
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
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, 2026Routine28
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Quality of Life and Care Deficiencies
Provide routine and 24-hour emergency dental care for each resident.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Smoke Deficiencies
Have properly installed hallway dispensers for alcohol-based hand rub.
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
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.
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
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.
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
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.
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Smoke Deficiencies
Install an approved automatic sprinkler system.
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Smoke Deficiencies
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Smoke Deficiencies
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Dec 16, 2025Complaint2
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.
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, 2025Complaint3
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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Nov 19, 2025Complaint2
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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, 2025Complaint3
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
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, 2025Complaint5
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.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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
Pacific Villa, INC
for profit
Chain Affiliation
Rollins-Nelson Healthcare Management
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
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
16 reviews from families & visitors
Medicare data downloads
Original nursing home datasets
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