Cycle 1
Health 2025-05-16 · Fire 2025-05-16
22 health deficiencies
Top issue: Environmental (4 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Laguna Hills, CA
Villa Valencia Healthcare Center
3-star overall rating with 3-star inspections with 22 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
25000 Calle De Los Caballeros, Laguna Hills, CA
(949) 609-7540
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
59
Certified beds
Average residents
52
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aspen Skilled Healthcare
Operator or chain grouping
Approved since
1991-06-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
34 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.22
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.90
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.65
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.75
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.00
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.87
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.38
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.86
CMS adjusted RN staffing hours
Adjusted total hours
3.29
CMS adjusted total nurse staffing hours
Case-mix index
1.93
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,328
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.10
Composite VBP score used to determine payment impact.
Payment multiplier
0.9844
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.07
Baseline 20.36% · Performance 20.01% · Measure score 3.07 · Achievement 3.07 · Improvement 0.56
Healthcare-associated infections
3.18
Baseline 6.94% · Performance 6.88% · Measure score 3.18 · Achievement 3.18 · Improvement 0
Total nurse turnover
4.59
Baseline 40.82% · Performance 44.93% · Measure score 4.59 · Achievement 4.59 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.29 hours · Performance 3.08 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.58% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 776 · Observed rate 7.73% · Lower 95% interval 7.47% |
| Discharge to community | 74.14% |
50.57%
23.6 pts better
|
Better than the National Rate · Eligible stays 774 · Observed rate 72.74% · Lower 95% interval 70.51% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99% |
95.27%
3.7 pts better
|
Numerator 496 · Denominator 501 |
| Falls with major injury | 0.4% |
0.77%
0.4 pts better
|
Numerator 2 · Denominator 501 |
| Discharge self-care score | 25.66% |
53.69%
28 pts worse
|
Numerator 68 · Denominator 265 |
| Discharge mobility score | 37.36% |
50.94%
13.6 pts worse
|
Numerator 99 · Denominator 265 |
| Pressure ulcers or injuries, new or worsened | 1% |
2.29%
1.3 pts better
|
Numerator 5 · Denominator 501 · Adjusted rate 0.92% |
| Healthcare-associated infections requiring hospitalization | 6.88% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 497 · Observed rate 6.04% · Lower 95% interval 4.95% |
| Staff COVID-19 vaccination coverage | 32% |
8.2%
23.8 pts better
|
Numerator 48 · Denominator 150 |
| Staff flu vaccination coverage | 52.08% |
42%
10.1 pts better
|
Numerator 75 · Denominator 144 |
| Discharge function score | 32.45% |
56.45%
24 pts worse
|
Numerator 86 · Denominator 265 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 145 · Denominator 145 |
| Transfer of health information to patient | 98.28% |
96.28%
2 pts better
|
Numerator 343 · Denominator 349 |
| Resident COVID-19 vaccinations up to date | 34.48% |
25.2%
9.3 pts better
|
Numerator 90 · Denominator 261 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
94.0%
3.7 pts better
|
81.7%
16 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 97.7% · Q3 97.2% · Q4 99.1% · 4Q avg 97.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
11.2%
2.1 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 8.5% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.7% |
93.2%
1.5 pts worse
|
79.7%
12 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
23.2%
1.2 pts worse
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 23.0% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-13 · Fire 2024-06-13
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-11-10 · Fire 2022-11-10
15 health deficiencies
Top issue: Nutrition and Dietary (6 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-16
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-06-05
F · Potential for more than minimal harm
2025-05-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-16
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-16
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-05
C · Minimal harm
2025-05-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-05
C · Minimal harm
2025-05-16
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-06-05
E · Potential for more than minimal harm
2024-06-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-15
E · Potential for more than minimal harm
2024-06-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-13
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-13
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-15
D · Potential for more than minimal harm
2022-11-10
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-11-10
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-11-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-11-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-11-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-11-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-02-06
B · Minimal harm
2026-01-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-02-06
D · Potential for more than minimal harm
2025-10-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-10-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-31
D · Potential for more than minimal harm
2025-10-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-31
D · Potential for more than minimal harm
2025-10-10
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2025-10-31
B · Minimal harm
2025-10-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-10-31
E · Potential for more than minimal harm
2025-05-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-05-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-05-16
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-16
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-16
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-16
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-16
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-16
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-06-12
B · Minimal harm
2025-05-16
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-06-12
B · Minimal harm
2025-05-16
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-06-12
B · Minimal harm
2025-04-02
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-12
B · Minimal harm
2025-02-20
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-17
D · Potential for more than minimal harm
2025-01-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-10
B · Minimal harm
2024-09-05
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-10-04
B · Minimal harm
2024-07-24
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-13
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-06-13
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-02-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-08
D · Potential for more than minimal harm
2023-10-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-27
B · Minimal harm
2023-08-24
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-06-12
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-07-23
F · Potential for more than minimal harm
2022-11-10
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2022-12-10
F · Potential for more than minimal harm
2022-11-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-12-10
D · Potential for more than minimal harm
2022-11-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-12-10
D · Potential for more than minimal harm
2022-11-10
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-12-10
D · Potential for more than minimal harm
2022-11-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-10
D · Potential for more than minimal harm
2022-11-10
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2022-12-10
D · Potential for more than minimal harm
2022-11-10
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-12-10
D · Potential for more than minimal harm
2022-11-10
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2022-12-10
D · Potential for more than minimal harm
2022-11-10
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2022-12-10
B · Minimal harm
2022-11-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-10
B · Minimal harm
2022-11-10
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2022-12-10
Penalties and ownership
What sits behind the stars
Ownership
Alhv LLC
Operational/Managerial Control · Organization
Caslmon, Timothy
Operational/Managerial Control · Individual
Nordfelt, Spencer
Operational/Managerial Control · Individual
Thompson, Stephen
Operational/Managerial Control · Individual
Tran, Roger
Operational/Managerial Control · Individual
Villahermosa-Calumpang, Cristina
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Laguna Hills Health And Rehabilitation Center
Laguna Hills, CA
1-star overall rating with 1-star inspections with 36 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Palm Terrace Healthcare & Rehabilitation Center
Laguna Hills, CA
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Freedom Village Healthcare Center
Lake Forest, CA
3-star overall rating with 3-star inspections with 17 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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