Avalon Villa: Unlicensed Nurse Gave Narcotics - CA
Staff 1 had worked at the facility since January 8, 2024, giving narcotic medications to residents with bone infections, fractures, and severe back pain. The worker used another person's nursing license to get hired and continued administering controlled substances until August 2025.
Federal inspectors found that between June 1 and August 15, 2025, Staff 1 administered opioids on 105 separate occasions to four residents alone.
Resident 2, who had fractures in the pelvis and lower back, received oxycodone 31 times from the unlicensed worker. Resident 3, with a broken thigh bone, got Percocet 34 times. Resident 4, diagnosed with paraplegia and back pain, received Norco 33 times.
Staff 1 also gave Resident 1, who had a bone infection in the right ankle and foot, Norco seven times during the same period.
The unlicensed worker administered tramadol and other controlled substances to six different residents during this timeframe, according to medication administration records reviewed by inspectors.
When inspectors examined Staff 1's personnel file on August 18, they discovered the facility had hired the worker using someone else's professional license. The Director of Staff Development confirmed Staff 1's file contained a California identification card and Social Security card, but no valid nursing license verification through the California Board of Vocational Nursing and Psychiatric Technicians system.
Instead, the file contained a copy of an unidentified individual's nursing license that did not match Staff 1's identification documents.
"The facility hired Staff 1 by using the unidentified individual's professional LVN license," the Director of Staff Development told inspectors.
The director acknowledged that allowing an unlicensed worker to function as a Licensed Vocational Nurse for over a year and a half "placed all residents at risk of unsafe care and potential harm."
Licensed Vocational Nurses must complete a state-approved educational program and pass a licensing exam to practice. They are qualified to administer controlled substances including opioids, which have high potential for addiction, abuse and misuse.
The facility's own policy, revised in April 2007, required employment background screening and license verification. The policy stated that if background checks revealed an employee did not hold a current valid license, "the employee would not be employed."
The administrator admitted the facility failed to follow its own procedures.
"The facility should have followed the policy but did not," the administrator told inspectors on August 19. "Staff 1 should not have been hired without license verification."
The administrator said not following the policy meant "the facility ended up hiring Staff 1 who was unlicensed and unqualified, and this placed all residents at high risk of harm."
Federal inspectors determined the deficient practice created "an increased risk for medication errors, unsafe care, adverse outcomes, and potential death to the residents."
The controlled substances Staff 1 administered included some of the most potent pain medications available by prescription. Oxycodone and Norco contain opioids that require careful monitoring and proper administration protocols to prevent overdoses, dangerous interactions, and addiction.
Percocet combines oxycodone with acetaminophen, creating additional risks if dosing is miscalculated. Tramadol, while considered less potent than other opioids, still carries risks of seizures, breathing problems, and dangerous interactions with other medications.
Residents receiving these medications had serious medical conditions requiring skilled nursing care. Resident 1's osteomyelitis, a bone infection, can spread to surrounding tissues and become life-threatening without proper treatment and monitoring.
Residents 2 and 3 had fractures requiring pain management during healing, while Resident 4's paraplegia and back pain needed ongoing assessment to prevent complications and ensure appropriate pain relief.
The medication administration records showed Staff 1 had been giving controlled substances to residents throughout the summer of 2025, with no apparent oversight or detection by licensed nursing staff or administrators.
Each administration of a controlled substance should involve verification of the correct resident, medication, dose, route, and timing. Licensed nurses are trained to recognize signs of adverse reactions, monitor for effectiveness, and document properly.
An unlicensed worker lacks this training and legal authority to make clinical decisions about narcotic medications. The worker cannot legally assess whether a resident needs pain medication, determine if the dose is appropriate, or recognize dangerous side effects.
The facility employed Staff 1 for 19 months before inspectors discovered the licensing fraud during a complaint investigation in August 2025.
During that time, Staff 1 had access to the facility's controlled substance supplies and administered narcotics to multiple residents on dozens of occasions. The worker signed medication administration records as a Licensed Vocational Nurse, creating false documentation of care provided.
The inspection found the facility failed to ensure Staff 1 met the qualifications required to administer narcotic medications to residents, violating federal requirements for employing licensed, certified, or registered staff in accordance with state laws.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, but noted it affected few residents. However, the administrator's own assessment suggested all residents faced high risk of harm from the facility's failure to verify licenses.
The case highlights gaps in nursing home hiring practices and oversight of medication administration, particularly for controlled substances that require the highest level of clinical judgment and legal authority to administer safely.
Staff 1's ability to work undetected for over a year while administering powerful narcotics to vulnerable residents with serious medical conditions demonstrates the potential consequences when facilities fail to follow basic verification procedures for licensed staff.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avalon Villa Care Center from 2025-08-19 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 August 19, 2025.
Staff 1 had worked at the facility since January 8, 2024, giving narcotic medications to residents with bone infections, fractures, and severe back pain.
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.