Victoria Post Acute Care

Name: Victoria Post Acute Care
Address: 654 S. ANZA, El Cajon, CA, 92020, US
Telephone: 6194405005

654 S. Anza, El Cajon, CA 92020 · San Diego County · 120 certified beds · avg 113 residents/day · certified since Mar 17, 2004

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

4.38

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.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Sep 28, 2022 · F-0580

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.

Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Nov 16, 2022 (Deficient, Provider has date of correction)

All citations in the current public record (41)

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
Jan 29, 2026	E · Potential for harm, repeated	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Jan 29, 2026	D · Potential for harm, one-off	The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Jan 29, 2026	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.
Jan 29, 2026	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.
Jan 29, 2026	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Jan 29, 2026	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.
Jan 29, 2026	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.
Jan 29, 2026	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.
Sep 4, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jul 31, 2025	D · Potential for harm, one-off	The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint
Sep 13, 2024	F · Potential for harm, facility-wide	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.
Sep 13, 2024	E · Potential for harm, repeated	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Sep 13, 2024	E · Potential for harm, repeated	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.
Sep 13, 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.
Sep 13, 2024	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Sep 13, 2024	D · Potential for harm, one-off	The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that.
Sep 13, 2024	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.
Sep 13, 2024	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.
Sep 13, 2024	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Sep 13, 2024	D · Potential for harm, one-off	The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Aug 30, 2024	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jul 24, 2024	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Jul 24, 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
Apr 17, 2024	D · Potential for harm, one-off	The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly. · from a complaint
Jan 26, 2024	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.
Jan 26, 2024	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Sep 28, 2022	▲ G · Actual 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.
Sep 28, 2022	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.
Sep 28, 2022	E · Potential for harm, repeated	The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Sep 28, 2022	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.
Sep 28, 2022	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.
Sep 28, 2022	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.
Sep 28, 2022	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Sep 28, 2022	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Sep 28, 2022	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Sep 28, 2022	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.
Sep 28, 2022	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Sep 28, 2022	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Sep 28, 2022	D · Potential for harm, one-off	The facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them.
Sep 28, 2022	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.
Sep 28, 2022	D · Potential for harm, one-off	The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (10 → 8).

Year	Citations	Serious (G–L)	Worst severity that year
2022	15	1	G ▲
2024	16	0	F
2025	2	0	D
2026	8	0	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)	4.38	4.31	3.95	top 34% in California; top 26% in the U.S.
Registered Nurse hours	0.62	0.61	0.69	top 31% in California; top 45% in the U.S.
Weekend total nurse staffing	4.07	3.90	3.50	top 29% in California; top 21% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.47	0.51	0.48	top 34% in California; top 36% in the U.S.
Total nursing staff turnover (%)	49.6	36.7	45.8	bottom 15% in California; bottom 38% in the U.S.
RN turnover (%)	50.0	38.1	42.9	bottom 29% in California; bottom 39% 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 4.03, RN 0.57, weekend 3.74. 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 - Corporation

Owner / manager	Type	Role	Stake	Since
Burnam, Soon	Individual	Corporate Officer	NOT APPLICABLE	09/10/2014
Dove, Edward	Individual	Managing Control - Governing Body	NOT APPLICABLE	12/01/2014
Dove, Edward	Individual	Operational/Managerial Control	NOT APPLICABLE	12/01/2014
Dove, Edward	Individual	ADP of the SNF	NOT APPLICABLE	07/10/2025
Ensign Services INC	Organization	ADP of the SNF	NOT APPLICABLE	12/01/2014
Fam, Anthony	Individual	Managing Control - Governing Body	NOT APPLICABLE	10/01/2023
Fam, Anthony	Individual	Operational/Managerial Control	NOT APPLICABLE	10/01/2023
Fam, Anthony	Individual	ADP of the SNF	NOT APPLICABLE	07/10/2025
Keetch, Chad	Individual	Corporate Officer	NOT APPLICABLE	03/01/2011
Lincare INC	Organization	Operational/Managerial Control	NOT APPLICABLE	12/01/2014
Oh, Katherine	Individual	Corporate Officer	NOT APPLICABLE	06/01/2025
Port, Barry	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	07/10/2025
Sato, Ami	Individual	Corporate Officer	NOT APPLICABLE	09/09/2024
Willits, Adam	Individual	Corporate Director	NOT APPLICABLE	01/01/2023

Questions to ask on your visit

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

"If my family member falls or their condition changes, exactly when and how will I be notified?"
"Could I join residents for a meal to see the food quality and temperature for myself?"
"If my family member is able to manage their own medications, would you allow it, and how is that decided?"
"How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
"How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
"Can you show me how medications are stored and secured on the units, including controlled drugs?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"How do you keep residents' medical records accurate, complete, and secure?"
"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	Flags
Villa Las Palmas Healthcare Center	0.0 mi	El Cajon, CA	★★★☆☆	3/5
Magnolia Post Acute Care	0.6 mi	El Cajon, CA	★★★☆☆	2/5	abuse
Stillwater Post-Acute	0.6 mi	El Cajon, CA	★★☆☆☆	2/5
Somerset Post Acute Care	0.7 mi	El Cajon, CA	★★★☆☆	3/5
San Diego Post-Acute Center	0.9 mi	El Cajon, CA	★☆☆☆☆	1/5	abuse
Parkside Health and Wellness Center	1.2 mi	El Cajon, CA	★★★★★	5/5
Cottonwood Canyon Healthcare Center	1.4 mi	El Cajon, CA	★★★☆☆	2/5
Granite Hills Healthcare & Wellness Centre, LLC	1.4 mi	El Cajon, CA	★★☆☆☆	2/5
Bradley Court	2.1 mi	El Cajon, CA	★★★★★	5/5
Country Hills Post Acute	2.2 mi	El Cajon, CA	★☆☆☆☆	1/5
The Royal Home	3.0 mi	El Cajon, CA	★★★★☆	3/5
Grossmont Post Acute Care	3.5 mi	La Mesa, CA	★★★★☆	4/5

Compare this facility with the 3 closest →

All facilities in El Cajon →

Facility data as of CMS processing date 2026-08-01. CCN 555804.

The Care File

Visit checklist — Victoria Post Acute Care

654 S. Anza, El Cajon, CA 92020 · 6194405005

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

Most serious findings on record:

▲ Sep 28, 2022 (F-0580, Actual 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.

Questions for the administrator:

☐ "If my family member falls or their condition changes, exactly when and how will I be notified?"
☐ "Could I join residents for a meal to see the food quality and temperature for myself?"
☐ "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
☐ "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
☐ "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
☐ "Can you show me how medications are stored and secured on the units, including controlled drugs?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "How do you keep residents' medical records accurate, complete, and secure?"
☐ "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 555804 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)