Victoria Care Center

Name: Victoria Care Center
Address: 5445 Everglades Street, Ventura, CA, 93003, US
Telephone: 8056421736

5445 Everglades Street, Ventura, CA 93003 · Ventura County · 188 certified beds · avg 181 residents/day · certified since Sep 18, 1991

Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)

4/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

4.53

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★☆4/5 · CMS overall rating: 5/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (23)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jul 10, 2025	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Apr 11, 2025	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Feb 27, 2025	E · Potential for harm, repeated	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Feb 27, 2025	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Feb 27, 2025	D · Potential for harm, one-off	The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Feb 27, 2025	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Feb 27, 2025	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Feb 27, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Feb 27, 2025	D · Potential for harm, one-off	The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Jan 31, 2025	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Jan 31, 2025	D · Potential for harm, one-off	The facility did not provide or arrange for a doctor to be available for emergencies 24 hours a day. · from a complaint
Jan 28, 2025	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Jan 28, 2025	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Oct 17, 2024	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Oct 17, 2024	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Jul 19, 2024	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Jul 2, 2024	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Jun 25, 2024	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Dec 3, 2023	D · Potential for harm, one-off	The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. · from a complaint
Oct 19, 2023	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Oct 19, 2023	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Apr 15, 2021	D · Potential for harm, one-off	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Apr 15, 2021	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (2 → 7).

Year	Citations	Worst severity that year
2021	2	D
2023	3	D
2024	5	D
2025	13	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	California avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	4.53	4.31	3.95	top 28% in California; top 22% in the U.S.
Registered Nurse hours	0.42	0.61	0.69	bottom 38% in California; bottom 26% in the U.S.
Weekend total nurse staffing	4.10	3.90	3.50	top 28% in California; top 20% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.35	0.51	0.48	bottom 45% in California; bottom 41% in the U.S.
Total nursing staff turnover (%)	30.1	36.7	45.8	top 29% in California; top 14% in the U.S.
RN turnover (%)	45.5	38.1	42.9	bottom 34% in California; bottom 43% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.53, RN 0.42, weekend 4.09. Staffing rating: 4/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Flagstone Healthcare Central LLC	Organization	5% or Greater Indirect Ownership Interest	100%	01/30/2006
The Ensign Group INC	Organization	Indirect Ownership Interest	NOT APPLICABLE	01/30/2006
Burnam, Soon	Individual	Corporate Officer	NOT APPLICABLE	01/30/2006
Caretrust GP LLC	Organization	ADP of the SNF	NOT APPLICABLE	11/01/2003
Caretrust Reit INC	Organization	ADP of the SNF	NOT APPLICABLE	11/01/2003
Ctr Partnership LP	Organization	ADP of the SNF	NOT APPLICABLE	11/01/2003
Cullifer, Jared	Individual	Corporate Officer	NOT APPLICABLE	01/01/2024
Ensign Services INC	Organization	ADP of the SNF	NOT APPLICABLE	11/01/2003
Everglades Health Holdings LLC	Organization	ADP of the SNF	NOT APPLICABLE	11/01/2003
Gardner, John	Individual	Managing Control - Governing Body	NOT APPLICABLE	11/01/2010
Gardner, John	Individual	Operational/Managerial Control	NOT APPLICABLE	11/01/2010
Gardner, John	Individual	ADP of the SNF	NOT APPLICABLE	11/01/2010
Keetch, Chad	Individual	Corporate Officer	NOT APPLICABLE	03/01/2011
Port, Barry	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	07/11/2025
Sato, Ami	Individual	Corporate Officer	NOT APPLICABLE	09/09/2024
Valiveti, Vinod	Individual	Managing Control - Governing Body	NOT APPLICABLE	03/09/2016
Valiveti, Vinod	Individual	Operational/Managerial Control	NOT APPLICABLE	03/09/2016
Valiveti, Vinod	Individual	ADP of the SNF	NOT APPLICABLE	03/09/2016
Willits, Adam	Individual	Corporate Officer	NOT APPLICABLE	10/30/2018

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
"Can you show me an example care plan, and how are families included when it's created and updated?"
"Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
"How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
"Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
"How do you keep residents' medical records accurate, complete, and secure?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection
Coastal View Healthcare Center	1.3 mi	Ventura, CA	★★★★★	4/5
Ventura Post Acute	1.7 mi	Ventura, CA	★★★★★	4/5
Oxnard Manor Healthcare Center	3.2 mi	Oxnard, CA	★★★★★	4/5
Glenwood Care Center	3.8 mi	Oxnard, CA	★★★★★	5/5
Shoreline Care Center	6.1 mi	Oxnard, CA	★★☆☆☆	2/5
Maywood Acres Healthcare	6.2 mi	Oxnard, CA	★★★★★	5/5
Santa Paula Post Acute Center	10.1 mi	Santa Paula, CA	★★★★☆	4/5
Camarillo Healthcare Center	10.2 mi	Camarillo, CA	★★★★★	4/5
St. John's Hospital Camarillo D/P SNF	11.5 mi	Camarillo, CA	★★★★★	5/5
Community Memorial Continuing Care Center	12.9 mi	Ojai, CA	★★★★★	5/5

Compare this facility with the 3 closest →

All facilities in Ventura →

Facility data as of CMS processing date 2026-08-01. CCN 555478.

The Care File

Visit checklist — Victoria Care Center

5445 Everglades Street, Ventura, CA 93003 · 8056421736

Health inspection rating 4/5 · CMS overall 5/5· Fines (3y): $0

Questions for the administrator:

☐ "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
☐ "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
☐ "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
☐ "How do you keep residents' medical records accurate, complete, and secure?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 555478 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)