Avalon Villa Care Center
AVALON VILLA CARE CENTER in LOS ANGELES, CA — inspection on August 19, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of the facility's policy and procedure (P&P) titled, Administering Medications, revised 4/2019, the P&P indicated Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so.
During a review of the facility's P&P titled, Controlled Substances, revised 11/2022, the P&P indicated the facility would comply with all laws and regulations relating to handling and documentation of controlled medications.
The P&P indicated only licensed nursing personnel would have access to scheduled medications-controlled substances.
056023 08/19/2025
Avalon Villa Care Center 12029 Avalon Blvd Los Angeles, CA 90061
During a concurrent interview and record review on 8/18/2025 at 10:45 a.m., with Director of Staff Development (DSD), Staff 1's personnel file was reviewed.
The personnel file indicated Staff 1 was hired to work in the facility as a LVN on 1/8/2024, and did not have proper documentation of a valid professional LVN license.
The DSD stated Staff 1's personnel file contained a California Identification Card (ID) and Social Security (SS) card but did not contain evidence of a valid LVN license verification through the California Board of Vocational Nursing and Psychiatric Technicians (BVNPT) system.
The DSD stated she did not conduct a license verification for Staff 1 upon hire on 1/8/2024.
Upon request, the DSD conducted a license verification on 8/18/2025, through the California BVNPT system and the search revealed no record of an LVN license for Staff 1.
The DSD stated the facility hired unlicensed staff to work with the residents.
The DSD stated that by allowing unlicensed Staff 1 to function as a LVN, all residents were placed at risk for unsafe care and harm.
During an interview on 8/18/2025 at 1:45 p.m., the Director of Nursing (DON) stated that on 8/13/2025, it was brought to her attention that Staff 1 had been working in the facility as an LVN without a professional LVN license.
The DON stated this posed a significant risk, including improper medication administration, inaccurate documentation, and the potential for residents to receive unnecessary or inappropriate medications.
The DON stated by hiring unlicensed staff to function as an LVN without proper credentials or clinical competency created significant risks, including medication errors and improper treatments, which placed residents at risk for infection and misrepresented residents' condition, leading to unsafe care and adverse outcomes.
During a review of the facility's policy and procedure (P&P) titled, Licensure, certification, and Registration of Personnel, revised 4/2007, the P&P indicated the facility would conduct employment background screening and license verification and should the background reveal that the employee / applicant did not hold a current valid license, the employee would not be employed.
During an interview on 8/19/2025 at 1:18 p.m., the Administrator (ADM) stated the facility should have followed the P&P but did not.
The ADM stated Staff 1 should not have been hired without license verification and that not following the policy, the facility ended up hiring Staff 1 who was unlicensed and unqualified, and this placed all residents at high risk of harm.
During a review of the facility's Job Description- Administrator, dated 2023, the Job Description indicated the ADM was responsible for ensuring the credentialing process was completed for all licensed staff providing services in the facility.
056023 08/19/2025
Avalon Villa Care Center 12029 Avalon Blvd Los Angeles, CA 90061
During a concurrent interview and record review on 8/18/2025 at 10:45 a.m., with Director of Staff Development (DSD), Staff 1's personnel file was reviewed.
The personnel file indicated Staff 1 was hired to work in the facility as a Licensed Vocational Nurse (LVN, an entry level healthcare provider who must complete a state approved educational program and pass a licensing exam to practice) on 1/8/2024, and did not have proper documentation of a valid professional LVN license.
The DSD stated Staff 1's personnel file contained a California Identification Card (ID) and Social Security (SS) card but did not contain evidence of a valid LVN license verification through the California Board of Vocational Nursing and Psychiatric Technicians (BVNPT) system.
The DSD stated Staff 1's employee file contained a copy of a LVN license of an unidentified individual which did not match Staff 1's ID and SS card.
The DSD stated the facility hired Staff 1 by using the unidentified individual's professional LVN license.
The DSD stated by allowing unlicensed Staff 1 to function as an LVN for over a year and a half placed all residents at risk of unsafe care and potential harm.
During a concurrent interview and record review on 8/19/2025 at 1:18 p.m., with the Administrator (ADM), the facility's policy and procedure (P&P) titled, Licensure, Certification, and Registration of Personnel, revised 4/2007 was reviewed.
The P&P indicated the facility would conduct employment background screening and license verification, and should the background reveal that the employee / applicant did not hold a current valid license, the employee would not be employed.
The ADM stated the facility should have followed the P&P but did not.
The ADM stated Staff 1 should not have been hired without license verification.
The ADM stated not following the policy, the facility ended up hiring Staff 1 who was unlicensed and unqualified, and this placed all residents at high risk of harm.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.