Avalon Villa Care Center: Unsafe Discharges - CA
Federal inspectors found the facility discharged three residents between October and November 2024 by labeling their departures as "against medical advice" — even though none of the residents requested discharge or knew they had been removed from the facility roster.
All three men had been granted approved four-hour passes to leave the facility. When they didn't return by the deadline, staff automatically discharged them and marked the departures as the residents' choice to leave against medical advice.
The practice placed residents at risk and violated federal discharge protections, inspectors determined during their January 2025 review.
Resident 117's case illustrated the dangers. The man had a broken right thigh bone with surgical hardware that had moved out of position. His psychiatric progress note from November 7, 2024, showed he suffered from major depressive disorder and was anxious about not having housing in the community. Social services was working to relocate him.
On November 8, the Social Services Director spoke with Resident 117 about his approved pass and the four-hour time limit. The conversation included discussion of referring him to a housing coordinator. Nothing in the record indicated he wanted to leave permanently or planned not to return.
The next day, Resident 117 left on his approved pass but didn't return within four hours. Staff couldn't reach him by phone.
At 12:33 a.m. on November 9, a progress note recorded that Resident 117 was "discharged from the facility against medical advice" due to exceeding the time limit. The note didn't indicate staff had explained the discharge to him or obtained his consent.
When Resident 117 returned to the facility at 7:15 a.m., staff told him he had been discharged and was now trespassing. Registered Nurse 1 called law enforcement, who removed him from the premises. He was told he could collect his remaining belongings two days later.
He came back that afternoon.
"Resident 117 returned to the facility and was very aggressive and brandishing a large knife," the progress note stated. "Resident 117 was yelling expletives." Staff called police again, but officers never arrived. The man collected his belongings and left.
Inspectors couldn't reach Resident 117 in January — his phone number was disconnected.
The Director of Nursing told inspectors that Resident 117's discharge "was not safe." The facility "did not know Resident 117's whereabouts, or if there was a reason he did not return within the four-hour timeframe" when they discharged him.
Registered Nurse 1 acknowledged the problems with the process. She told inspectors an against-medical-advice discharge was supposed to be requested by the resident, not initiated by staff. The facility was required to explain risks and benefits and encourage the resident to stay.
"Resident 117's discharge was not safe," she said. "Discharging Resident 117 AMA indicated the discharge was Resident 117's choice, and this was not confirmed with Resident 117."
The Social Services Director said discharging residents without housing was dangerous because they "could be exposed to crime and poor weather conditions, which could negatively impact their safety and well-being."
Two other residents faced identical treatment.
Resident 320, who used a wheelchair and had diabetes requiring blood sugar monitoring, left on an approved pass October 12, 2024. Staff had no phone number to reach him. When he didn't return by the four-hour limit, they discharged him as against medical advice.
Progress notes showed no contact with Resident 320 and no knowledge of why he hadn't returned. The Director of Nursing said there was "no documentation indicating Resident 320's safety, well-being, or disposition were identified by facility staff prior to his discharge." His whereabouts remained unknown during the January inspection.
Resident 321 left October 5, 2024, in an electric wheelchair and was "alert and aware he was expected to return within four hours." He returned that evening, then left again on a second pass. He called the facility during his second outing to say he would return the next morning around 9 a.m.
He never did.
Staff discharged him against medical advice on October 7 without further contact. A month later, he returned to collect his belongings. Licensed Vocational Nurse 5 described him as "angry and appeared dirty as if he was living on the street."
The facility's own policies contradicted its practices. A 2012 policy required residents or their representatives to request immediate discharge and sign a release form acknowledging the risks of leaving against medical advice.
The Director of Nursing admitted the facility automatically discharged any resident who left on pass and didn't return by four hours or midnight — regardless of whether they requested discharge. She said law enforcement, state agencies, and the ombudsman were not notified when residents were discharged this way.
"Based on the facility P&P revised 2012, Resident 117, Resident 320, and Resident 321 did not meet the criteria for an AMA discharge," she told inspectors.
None of the three men signed acknowledgment forms. The Medical Records Director confirmed Resident 117 couldn't sign because "he was not in the facility and was unable to be contacted by telephone" — highlighting the fundamental problem with the discharge process.
Federal regulations require facilities to provide 30-day written notice for most discharges. The facility's policy acknowledged this requirement but didn't list "failure to return by midnight while on pass" as an exception.
The violations placed all facility residents at risk, inspectors found, because the automatic discharge policy meant anyone could lose their bed and belongings simply by being delayed during an approved outing — whether due to transportation problems, medical emergencies, or other circumstances beyond their control.
The case of Resident 117 returning with a knife demonstrated how the unsafe discharge practice could endanger staff and other residents when discharged individuals returned confused, angry, or desperate about their sudden homelessness.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avalon Villa Care Center from 2025-01-31 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
AVALON VILLA CARE CENTER in LOS ANGELES, CA was cited for violations during a health inspection on January 31, 2025.
All three men had been granted approved four-hour passes to leave the facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.