Veterans Home Of California - Chula Vista

In the surveyor’s words

From the most serious findings on record at Veterans Home Of California - Chula Vista, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 5, 2024

  Based on observation, interview and record review, the facility failed to provide adequate/ necessary supervision to prevent elopement (when a resident leaves the premises or safe area without the facility's knowledge and supervision) with injury for one of three sampled residents (Resident 1), when the facility staff failed to assess level of supervision required for safety for Resident 1, who was cognitively impaired, for elopement risk when he attempted to leave the facility and fell at the facility's back gate on 6/5/2023. In addition, the facility staff did not follow the facility expectation as directed to visualize the resident every two hours. Resident 1 eloped and fell approximately one mile from the facility, and was missing for approximately 9 hours, on 1/24/2024. […]

• No harm, potential for more than minimal, widespreadF812Mar 2, 2023

  Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. There were multiple areas in the kitchen that were not clean and covered with brown debris. 2. The can opener's blade and base in the kitchen was not kept in a sanitary condition. 3. There were four gray colored plastic food racks, and one silver colored food rack that were not kept in a sanitary condition. 4. The kitchen's cutting boards surfaces were heavily marred. 5. There were multiple areas in the kitchen, kitchen equipment, storage areas were not clean and had buildup. 6. There was ice buildup on the light fixture and plastic curtain in the walk-in freezer. 7. […]

• No harm, potential for more than minimal, patternF584Jan 16, 2026

  Based on observation, interview, and record review, the facility failed to maintain a safe, comfortable, and sanitary environment when: 1.One of the shower rooms, Room A729, was found with broken tiles and an exposed wall cavity. This failure had the potential to result in exposing residents to pests and contaminants, compromising the hygiene and safety of a medically vulnerable population of 107 residents.2. The shared bathroom for one of 24 sampled resident's (Resident 39) and one unsampled resident (Resident 34), had a large, unsealed hole located directly above the toilet. […]

• No harm, potential for more than minimal, patternF865Jan 16, 2026

  Based on interview and record review, the facility identified building damage that remained consistent during the public safety committee meeting reports from 4/23/2024 to 10/23/2025, and the facility's Quality Assurance and Performance Improvement failed to address a plan of repair to correct the issue. This failure had the potential to adversely affect the health of residents.Cross-reference F584Findings:During a review of the facility's Health and Safety Committee Meetings Records, from 4/23/2024 to 10/23/2025, the meeting records indicated that the walls have holes, scrapes, and paint damage, and this remains consistent.During an interview on 1/15/2025 at 4:16 p.m. […]

• No harm, potential for more than minimal, patternF812Jan 30, 2025

  50674 Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation measures were maintained in the kitchen according to standards of practice and facility policy when: 1. One plastic bin containing white colored powder was observed underneath food preparation counter and was unlabeled and undated. 2. One bag of opened frozen peanut butter cookies was observed in the walk-in freezer and three sandwiches observed in the refrigerator were unlabeled and undated. 3. One bag of food labeled, meat substitute was observed expired in the walk-in freezer. 4. […]