Knolls West Residential Care

    16890 Green Tree Blvd, Victorville, CA, 92395
    2.7 · 24 reviews
    • Assisted living
    • Memory care
    • Skilled nursing
    AnonymousLoved one of resident
    2.0

    Pleasant rehab but unsafe staffing

    I had a mixed, frustrating experience. The grounds, furnishings and activities (bingo, crafts, salon, courtyard) are pleasant and some nurses/therapists were excellent - rehab helped - but staffing is inconsistent. Too often calls went unanswered for 40-60 minutes, residents were left unattended (bedsores, diapers full, oxygen unplugged), sanitation and odor were problems, and communication/theft issues left me distrustful. Food and room quality varied, billing is pricey/confusing, and you basically must advocate in person. I would not trust this place for long-term care unless you or a family member can closely supervise.

    Pricing

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    Amenities

    2.71 · 24 reviews

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      2.3
    • Staff

      2.5
    • Meals

      2.9
    • Amenities

      3.0
    • Value

      1.6

    Pros

    • Some staff are caring, helpful, and go above and beyond
    • Well-kept grounds and pleasant outdoor courtyard/flowers
    • Clean, uncluttered rooms reported by multiple reviewers
    • Private touches in rooms (shelves, cork boards, personal TV) in double-occupancy rooms
    • Rehabilitation/therapy services that helped some residents improve
    • Activities offered (bingo, Bible studies, crafts) and social opportunities
    • On-site amenities such as hair salon and common leisure rooms
    • Occasional very good meals and engaging dining experiences reported
    • Frequent small treats (e.g., ice cream) and an active social environment
    • Medicare coverage accepted for some services (short-term rehab)
    • Staff willing to work with families and personalize care in some cases
    • Large lobby and open common spaces noted positively

    Cons

    • Highly inconsistent staff quality and high variability across shifts
    • Chronic understaffing leading to long wait times for assistance
    • Slow or sporadic response to nurse call light (reports of 40–60 minute waits)
    • Reports of neglect: bedsores, residents left in bed/wheelchair for hours
    • Poor sanitation in some areas, strong urine odor reported
    • Serious safety incidents (oxygen unplugged, staples left in after surgery)
    • Unaddressed medical concerns and delayed recognition of infections or declining conditions
    • Poor communication with families and difficulty reaching residents/staff
    • Management issues: unresponsive administrators, alleged abusive/greedy behavior
    • Inconsistent or declining food quality (reports of slop/poor meals and tray service)
    • Facility maintenance problems (dirty carpet, holes in walls, painted-over repairs)
    • Incidents of theft and security/administrative lapses (missing license/insurance card)
    • Billing confusion and potential out-of-pocket costs for long-term stays
    • Locked doors or restricted access causing family concern
    • Some reviewers advise the facility is unsuitable for long-term residence without family oversight

    Summary review

    Overall impression: The reviews for Knolls West Residential Care are highly mixed and polarized. Multiple reviewers describe excellent, attentive care and a pleasant environment, while many others report serious neglect, safety lapses, and management problems. The most consistent pattern across the reviews is variability: experiences appear to depend heavily on staffing levels, specific shifts, individual caregivers, and whether family members are frequently present and advocating for the resident. As a result, the facility appears to provide good outcomes for some residents (particularly short-term rehab patients with active family involvement) but has multiple, documented instances of substandard care for others.

    Care quality and safety: A major theme is inconsistency in clinical care. Positive reports highlight nurses and aides who are skilled, encouraging, and effective with therapy; several reviewers explicitly praised the rehabilitation and therapy staff for good outcomes. Conversely, many reviews report alarming safety and neglect issues: bedsores from lack of turning, residents left immobile in bed or chairs for extended periods, long delays (some cited 40–60 minutes) in responding to call lights, full diapers left unattended, oxygen equipment found unplugged, and staples left in post-surgical wounds for extended periods. Some families reported failures to recognize or respond promptly to serious medical conditions (pneumonia, UTIs, electrolyte imbalance) leading to hospital transfers. These reports point toward staffing shortages, inadequate monitoring, and inconsistent clinical oversight on some shifts.

    Staffing, responsiveness, and communication: Staffing shortages and uneven staff performance are repeatedly cited as root causes of many problems. Reviewers describe caring, friendly staff when family is present or during certain shifts, but impatience, rudeness, and inattentiveness at other times. Several reviewers said staff ‘‘do their best’’ but are overstretched; others described outright neglectful or hostile behavior. Communication with families is another common concern: difficulty reaching residents, poor or infrequent updates, phone calls being hung up on, and administrators who claim no other complaints despite families reporting problems. Billing and administrative communication also drew criticism — long-term billing confusion and potential out-of-pocket costs beyond Medicare were mentioned.

    Facilities and cleanliness: Opinions about the physical facility vary widely. Many reviewers praised tidy, bright rooms, uncluttered common areas, a large lobby, and well-kept grounds with flowers and a pleasant courtyard. Others described dirty carpets, strong urine odors, painted-over repairs, holes in walls, and an overall dark, dingy appearance. These contradictions suggest uneven maintenance and cleaning practices across units or floors rather than a uniformly clean or dirty facility.

    Dining and activities: Activity programming is a clear positive for many families — bingo, Bible study, crafts, hair salon services, social events, and frequent treats such as ice cream were appreciated and contributed to residents’ social engagement. Dining received mixed reviews: some current or short-term rehab residents enjoyed meals and found them good, while others described a decline in meal quality over time, complaints of ‘‘slop,’’ and reliance on tray service. Food quality may be another area with variability depending on timing and regime (short-term rehab vs long-term residence).

    Management and culture: Several reviewers raised concerns about management attitude and culture. Reports include an allegedly toxic environment, administration focused on money, unresponsiveness to complaints, and even abusive behavior by leadership. These concerns, combined with reports of inconsistent care and maintenance, point to systemic issues in oversight, staffing policies, and quality assurance. Positive reviews that praise management exist as well, reinforcing the pattern of uneven leadership impact across different units or periods.

    Patterns and implications for prospective families: The dominant pattern is that Knolls West can provide very good short-term rehabilitation and a pleasant social environment when staffing is adequate and engaged families advocate for care, but it may be risky as a long-term placement without regular family oversight. Serious safety incidents reported by multiple reviewers (untethered oxygen, bedsores, delayed recognition of infection, staples left in wounds) are red flags that should prompt careful inquiry. Prospective families should specifically ask about staffing ratios, how the facility handles call-light response times and night coverage, clinical oversight (physician access, lab services), recent state survey or inspection results, maintenance and cleaning schedules, incident reporting, and billing practices. It would also be prudent to visit at different times (day/evening/weekend), talk to multiple families, and verify how the facility handles transitions from Medicare-covered rehab to long-term care and associated costs.

    Bottom line: Knolls West Residential Care shows a split record—capable of providing compassionate care, active programming, and successful rehab for some residents, but also associated with troubling incidents of neglect, poor communication, management concerns, and variable cleanliness. The facility may be appropriate for short-term rehab if you can verify current staffing and oversight, but many reviewers strongly caution against relying on it for long-term care without frequent family involvement and careful vetting.

    Location

    Map showing location of Knolls West Residential Care

    About Knolls West Residential Care

    Knolls West Residential Care, also called Knolls West Post Acute, sits at 16890 Green Tree Blvd in Victorville, CA, and offers both residential care and adult daycare services for adults who need help with daily living or more complex medical needs, and you can see they focus on treating a full range of conditions, since there's 24-hour skilled nursing care from licensed nurses, along with supervision and a bedside emergency call system that always has a nurse on duty, which adds a sense of safety for residents and their families, and because the staff there is known for being friendly and kind, residents can expect help from someone who tries to build rapport and understand exactly what each person needs, and they take it one step further by making sure each resident gets a personalized care plan that can change when needs do.

    Meals at Knolls West get special attention because they're recognized for their quality and nutrition, with awards for best meals and dining, and all food is prepared with good ingredients, and those who need help with diabetic or incontinence care, or even non-ambulatory care, find staff are trained to support these conditions, and there's medication management so people won't miss important doses. They've built a culture that encourages everyone to join in activities, and there are programs for social, physical, mental, and emotional engagement-many of these activities have earned them awards too, which is nice even if awards aren't everything, and they offer therapy, including physical therapy for those who can't get out of bed, so there's always a push to keep minds and bodies active when possible.

    There are assisted living services for seniors, rehabilitation services aimed at restoring health, and staff on site at all hours to help with bathing, dressing, or anything else needed during the day or night, and the adult daycare center means those who aren't staying overnight can still join for daytime support and activities. The environment feels supportive and caring because the team tries to see each person as an individual, looking out for both well-being and independence, and that's pretty important for people dealing with illness or needing extra help as they get older.

    People often ask...

    State of California Inspection Reports

    22

    Inspections

    2

    Type A Citations

    2

    Type B Citations

    4

    Years of reports

    08 Aug 2025
    Found the home operated as approved with no deficiencies identified. Observed proper safety features (working smoke and CO detectors, fire extinguishers), adequate staffing, secure medication storage, sufficient food supplies, and complete resident and staff records.
    • § 9058
    09 Dec 2024
    Determined that the allegation that meals were not provided in a timely manner and the allegation that medications were not dispensed as prescribed are unfounded.
    22 Aug 2024
    Found no deficiencies and one technical violation after an unannounced visit. The home was clean and safe, with adequate staffing, proper medication storage, and records for residents and staff reviewed.
    22 Aug 2024
    Inspection found no deficiencies at the facility and issued one technical violation for an outdated Emergency Disaster Plan.
    27 Oct 2023
    Conducted an unannounced case management visit, collected records, interviewed the administrator, and toured resident rooms; no deficiencies observed.
    27 Oct 2023
    No deficiencies were observed during the visit and the inspection report was discussed with the facility administrator.
    31 Jul 2023
    Identified an allegation that several staff were working without required criminal record clearances, and that two additional staff lacked transfer of clearance, neither of whom were associated with this home. Civil penalties were issued.
    31 Jul 2023
    Identified deficiencies in staffing and record-keeping during the inspection.
    • § 87355(e)(3)
    • § 87412(d)
    • § 87355(e)
    04 Nov 2022
    Investigated two allegations: Allegation 1—staff threatened a resident; Allegation 2—resident was not allowed to leave for a higher level of care. Based on interviews with residents, outside vendors, and staff, the incidents could not be determined, there was not a preponderance of evidence to prove or disprove them, and no deficiencies were cited.
    04 Nov 2022
    Unsubstantiated allegations of staff threatening a resident and refusing to allow a resident to leave for a higher level of care. No deficiencies were found during the visit.
    12 Oct 2022
    Investigated Allegations 1-8; evidence did not clearly prove or disprove them, but observations showed meals provided to ambulatory and non-ambulatory residents, toileting and bathing needs met, residents participating in activities, staffing was adequate, and no evidence of residents being left in bed all day, nor restrained, or verbally abused observed.
    12 Oct 2022
    Investigated allegations of staff not providing meals, meeting toileting and bathing needs, having adequate staffing, and improperly restraining or leaving residents in bed; determined insufficient evidence to confirm or refute these claims.
    08 Jun 2022
    Found that infection-control measures were in place, PPE and hygiene supplies were adequate, and staff wore masks; interviews indicated vaccination status and monitoring procedures for COVID-19 symptoms were in place. No deficiencies were noted, and an exit discussion was conducted.
    08 Jun 2022
    Confirmed no deficiencies found during inspection, facility in compliance with infection control measures and health/safety guidelines.
    08 Jun 2021
    Found comprehensive infection control measures in place, including a screening area, signage, adequate hand hygiene and cleaning supplies, a 30+ day PPE supply, a designated infection control lead, and plans for testing, isolation, cleaning schedules, and resident monitoring, with no deficiencies identified.
    08 Jun 2021
    Confirmed no deficiencies in infection control measures at the facility during the annual inspection.
    20 Apr 2021
    Found the eviction allegation unfounded after interviews and records review; the referenced resident was never admitted and did not reside at the property, and no deficiencies were cited.
    20 Apr 2021
    Confirmed unfounded complaint of illegal eviction. No deficiencies cited during visit.
    13 Apr 2021
    Reviewed case-management follow-up on a resident's death; requested copies of the resident's ID/emergency information, admission agreement, physician's report, centrally stored medication log, March/April 2021 notes, and special incident reports, and noted that a coroner's report and death certificate would be obtained when available. No deficiencies cited; exit interview conducted with the administrator by telephone.
    13 Apr 2021
    Reviewed death of a resident, requested documentation from facility, no deficiencies cited during visit.
    17 Feb 2021
    Investigated the allegation that a resident was not admitted and did not reside at this site; found the resident was at the SNF on the same property, making the complaint unfounded with no deficiencies cited.
    17 Feb 2021
    Investigated the allegation regarding a resident's care and found it unfounded, as the resident was never admitted and resided at a different facility. No deficiencies cited.

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