Veterans Home Chula Vista

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with CNA Marlone Temple and CNA Vicky Magno. LPA met with Administrator, Kathy Gabriel. All staff present had current criminal record clearances. According to the facility’s license, the facility has a maximum capacity for fifty-five (55) residents, of whom all may be ambulatory or non-ambulatory, but none may be bedridden. During today’s inspection, there were a total of twenty-two (22) residents in care, and all were ambulatory. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter doors, and neither of these were present. LPA, accompanied by Licensee’s staff, toured the interior and exterior of the facility and inspected all common areas and multiple resident bedrooms. LPA interviewed multiple residents and multiple staff. LPA reviewed care records for multiple residents and personnel records for multiple active staff. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was complaint at 72 F. Where tested, hot water temperature at taps accessible to residents were also compliant. Appliances to preserve perishable food and medications were also compliant in temperature. [CONTINUED ON LIC 809-C] (continue from LIC809) There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were available. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in their original pharmacy packaging, and in locked areas. Confidential records were stored in locked areas. Required licensing postings were observed in visible areas of the facility. Carbon monoxide detectors, smoke detectors, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguishers had been serviced within the last twelve (12) months. No fireplaces or pools/bodies of water were observed on the premises. Per the Licensee, no firearms or ammunition are kept at the facility. Fire/disaster drills were performed at required intervals. There were reserve supplies of Personal Protective Equipment (PPE). The seven (7) resident files which were randomly selected and reviewed contained required documents. The seven (7) employee files which were randomly selected and reviewed contained required documents. Licensee also had proof that the staff met other initial and ongoing training requirements, to include training on the facility's written LIC610E Emergency Disaster Plan (July 10, 2026) and PPE within the last twelve (12) months. No deficiencies were cited during today's annual inspection. An exit interview was conducted with Administrator Kathryn Gabriel, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.the state’s words, verbatim · CDSS document, Aug 23, 2026

Allegation investigated: Staff hit resident

On April 16, 2026, Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to the facility to deliver findings related to the allegation in this complaint. LPA was greeted by Administrator Kathy Gabriel and informed her of the purpose of the visit. On February 18, 2026, Community Care Licensing (CCL) received a complaint alleging that staff struck Resident 1 (R1). Per the abuse report SOC 341 dated 02/18/2026, staff reported to the supervising registered nurse that R1 stated that on the night of 02/12/2026, a female staff member prevented R1 from watching television in the resident lounge, took the remote control, and “smacked” R1 in the face. The supervising registered nurse spoke with R1 at that time; however, R1 declined to provide details. The nurse documented no visible redness or bruising. On 02/17/2026, R1 was reassessed by a registered nurse and Administrator Kathy Gabriel, and no injuries or signs of distress were observed. (continue at LIC9099C) Unsubstantiated (continue from LIC9099) The Department’s investigation included a facility tour, interviews with R1, staff, eight (8) resident witnesses, and outside sources, as well as a review of records including the SOC 341 report, internal incident report, LIC 624, progress notes, and nursing assessments. On 02/19/2026, LPA interviewed R1 at the facility. R1 was observed to be alert and able to engage in conversation. R1 reported that several days prior, after 10:00 p.m., while watching television in the lounge, a female staff member became upset, took the remote control from R1, and struck R1 in the face. R1 stated that several staff members were talking loudly, making it difficult to hear the television, and R1 increased the volume. R1 reported that the staff member yelled at R1 to be quiet and go to sleep, refused to return the remote, and then slapped R1. R1 stated R1 left the lounge feeling upset and reported the incident the following morning. R1 reported R1 did not tell other residents due to embarrassment and did not inform family to avoid causing problems with staff. R1 stated this was the only time a staff member had hit R1 and reported no additional concerns. R1 was unable to identify the staff member involved, provide a specific date, or identify any witnesses present. R1 stated R1 currently feels safe in the facility. Staff interviews were conducted with supervisory staff and staff working during the relevant shifts. Staff reported that R1 initially stated that a female staff member took the remote control and slapped R1; however, during follow-up, R1 declined or was unable to provide additional details. Staff reported that R1 was assessed following the allegation, and no visible injuries, including redness, bruising, or swelling, were observed. R1 was noted to be at baseline and not in distress. Staff reported that an internal investigation was conducted, including interviews with staff on duty, and all staff denied the allegation and reported they did not witness any incident or inappropriate interaction between staff and residents. Staff reported that R1 was unable to identify any staff on duty at the time of the alleged incident. Staff further reported that there have been no prior similar incidents or concerns regarding staff performance. (Continue on LIC9099C) (continue from LIC9099C) Eight (8) residents were interviewed regarding the alleged incident. None reported being present during the alleged incident, observing any staff strike or mistreat R1, hearing any argument or disturbance, or receiving any disclosure from R1 regarding being struck. None of the residents reported observing injuries or distress in R1. No resident provided information to corroborate the allegation. A review of records, including the SOC 341 abuse report, LIC 624 incident report, progress notes dated 02/13/2026 through 02/17/2026, and nursing assessments, indicated no visible injuries such as redness, bruising, or swelling, and no documented distress or behavioral changes. Documentation reflected that the facility reported the incident in a timely manner and completed required follow-up assessments as required per Title 22 regulations. Although R1 provided a consistent statement that R1 was struck by a staff member and appeared credible during the interview, R1 was unable to identify the staff member involved, provide a specific date, or identify any witnesses. No staff or residents reported witnessing or hearing the alleged incident, and no physical evidence or documentation supported the occurrence of injury. Based on the investigation, including interviews, observations, and record review, there is insufficient evidence to substantiate the allegation. Therefore, the allegation that staff struck R1 is deemed unsubstantiated. An exit interview was conducted with Administrator Kathy Gabriel. A copy of this report and the Licensee Appeal Rights (LIC 9058 03/22) were provided at the time of the visit.the state’s words, verbatim · CDSS document, Apr 16, 2026 · control 08-AS-20260218102350

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Kathryn Gabriel. According to the facility’s license, the facility has a maximum capacity for fifty-five (55) residents, of whom all may be ambulatory or non-ambulatory, but none may be bedridden. Per LPA observation, LIC602 Physician’s Reports, and staff interviews: During today’s inspection, there were a total of twenty-two (22) residents in care, and all were ambulatory. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter doors, and neither of these were present. LPA, accompanied by Licensee’s staff, toured the interior and exterior of the facility and inspected all common areas and multiple resident bedrooms. LPA interviewed multiple residents and multiple staff. LPA reviewed care records for multiple residents and personnel records for multiple active staff. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] The facility’s ambient internal temperature was complaint at 72 F. Where tested, hot water temperature at taps accessible to residents were also compliant: Public Restroom #1 Sink was 112.1 F, Public Restroom #2 Sink was 108 F, Laundry Room Sink was 108.9 F, Room C207 Sink was 113.4 F, Room C305 Sink was 107.4 F. and Room C408 Sink was 113.5 F. Appliances to preserve perishable food and medications were also compliant in temperature. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were available. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in their original pharmacy packaging, and in locked areas. Confidential records were stored in locked areas. Required licensing postings were observed in visible areas of the facility. Carbon monoxide detectors, smoke detectors, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguishers had been serviced within the last twelve (12) months. No fireplaces or pools/bodies of water were observed on the premises. Per the Licensee, no firearms or ammunition are kept at the facility. Fire/disaster drills were performed at required intervals. There were reserve supplies of Personal Protective Equipment (PPE). The five (5) resident files which were randomly selected and reviewed contained required documents. The five (5) employee files which were randomly selected and reviewed contained required documents. Licensee also had proof that the staff met other initial and ongoing training requirements, to include training on the facility's written LIC610E Emergency Disaster Plan and PPE within the last twelve (12) months. No deficiencies were cited during today's annual inspection. However, LPA issued one (1) Technical Violation (TV) regarding updating clients’ Facesheets/Emergency Contact Sheets to include contact information for their respective dentists and any other health providers (the latter as applicable) (refer to the LIC9102-TV page). LPA also issued Technical Assistance (TA) regarding documenting the participation of responsible persons (RPs) at care conferences (refer to the LIC9102-TA page). An exit interview was conducted with Administrator Kathryn Gabriel, to whom a copy of this report, the LIC9102-TV page, the LIC9102-TA page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.the state’s words, verbatim · CDSS document, Aug 29, 2025

Allegation investigated: -Licensee neglect, contributing to resident’s skin breakdown. -Licensee did not meet resident’s incontinence care need. -Licensee did not provide responsible person with requested records.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced complaint visit to investigate the above allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Kathy Gabriel. The Complainant alleged that Licensee’s neglect contributed to Person #1 (P1’s) skin breakdown, that Licensee did not meet P1’s incontinence care need, and the Licensee did not provide requested records to P1’s responsible person. [See LIC811 Confidential Names List for a description of R1.] CCLD’s investigation involved an un unannounced facility tour/welfare check and a collateral visit. The Department also interviewed pertinent administrative records and interviewed relevant facility staff and outside sources. [CONTINUED ON LIC 9099-C] Unfounded [CONTINUED FROM LIC 9099] Records, interviews, and LPA observation unanimously showed: P1 was not a resident of the CCLD-licensed facility, either at present or during the timeframe of the complaint allegations. Based on records and interviews, these three (3) allegations are Unfounded, meaning they are false, could not have happened, and/or are without a reasonable basis. We have therefore dismissed the allegations, and no deficiencies were cited. An exit interview was conducted with the Gabriel, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 6, 2025 · control 08-AS-20250127091151

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced health and safety visit to Veterans Home Chula Vista for thirteen (13) residents temporary relocated from Veterans Home of California West LA, address: 11500 Nimitz Avenue, Los Angeles, CA, 90049. The residents' home facility in Los Angeles was temporarily closed due to the widespread wild fires disaster in the area. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to facility Administrator Kathryn Gabriel. LPA was informed by Administrator Gabriel that 12 of the temporary residents had just left earlier this morning back to their home facility at 9:00 am. One (1) had stayed with nearby family and drove themselves back to their home facility. The residents stayed at Veterans Home Chula Vista from 1/11/25-1/17/25. No records were collected during the visit. LPA did not observe any health or safety concerns. No deficiencies were cited during the inspection. An exit interview was conducted with Administrator Gabriel, to whom a copy of this report was provided. Their signature below confirms receipt of this document.the state’s words, verbatim · CDSS document, Jan 17, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Kathryn Gabriel. According to the facility’s license, the facility has a maximum capacity of fifty-five (55) residents, of which all may be ambulatory or non-ambulatory but none may be bedridden. Per LPA observation, LIC602 Physician’s Reports, and staff interviews: During today’s inspection, there were a total of five twenty (22) residents in care, of whom twenty (20) were ambulatory and two (2) were non-ambulatory and none were bedridden. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter, and none of these were present. LPA reviewed records for multiple residents and multiple staff. LPA interviewed multiple residents and multiple staff. LPA, accompanied by Licensee’s staff, also toured the interior and exterior of the facility, and inspected all common areas and multiple resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was complaint at 74 F. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Where tested, hot water temperature at taps accessible to residents were all compliant: Public Restroom #1 Sink was 116.6 F, Public Restroom #2 Sink was 116.1 F, Kitchenette Room Sink was 115.3 F, Laundry Room Sink was 116.2 F, Room C205 Sink was 116.2 F, Room C306 Sink was 115.3 F, Room C404 Sink was 117.3 F, and Room C408 Sink was 114.4 F. Appliances to preserve perishable food were also all compliant in temperature: Main Walk-In Refrigerators were 32 F and 37 F, respectively. Main Walk-In Freezer was -3 F. Kitchenette Refrigerator was 35 F, and Kitchenette Freezers were -3 F and 0 F, respectively. The Medication Room Refrigerator was 40 F. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, active fireplaces, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. No pools or bodies of water were observed on the premises. Per the Licensee, no firearms or ammunition are kept at the facility. Fire detection system, carbon monoxide detectors, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguishers were serviced within the last twelve (12) months. Required licensing postings were observed in visible areas of the facility. Fire/disaster drills were performed at required intervals. There were reserve supplies of Personal Protective Equipment (PPE) and staff had been trained on PPE within the last twelve (12) months. No deficiencies were observed or cited during today's annual inspection. LPA issued Technical Assistance (TA) regarding medical assessments/physician’s reports and physical organization of personnel records (refer to the attached LIC 9102-TA pages). An exit interview was conducted with Gabriel, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TA pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.the state’s words, verbatim · CDSS document, Aug 9, 2024

Allegation investigated: Staff are not following physician’s orders Staff are not properly trained Staff did not safeguard resident’s property

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Administrator Kathryn Gabriel and discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff, clients and outside agency. It was reported to CCL that staff are not following physician’s orders, staff are not properly trained, and staff do not safeguard resident’s property. [Continued on LIC 9099-C] Unsubstantiated [Continued from LIC 9099] Regarding the allegation, staff are not following physician’s orders, it was reported that C1 perceived neglect due to lack of communication from medical providers regarding medication and lab results. Interviews with residents revealed no concern for staff not following doctors orders. Interviews with facility staff revealed no concerns for staff not following doctor’s orders and all reported that they follow all doctor’s order’s. Interview with outside source reported no concerns for the facility. Regarding the allegation, staff are not properly trained, C1 reported that they are being over medicated and staff are under-trained. Interviews with residents revealed no issues surrounding medication and no concerns for staff. Interviews with facility staff revealed that all staff are properly trained. Interview with outside source reported no concerns for the facility. Regarding the allegation, staff do not safeguard resident’s property, C1 reported that personal belongings were being stolen. Interviews with current residents revealed no concerns for missing belongings. Interviews with facility staff also revealed no concerns for resident’s personal belongings not being safeguarded. Interview with outside source reported no concerns for the facility. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. No deficiencies were cited today. An exit interview was conducted with Administrator Kathryn Gabriel. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Administrator whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, May 23, 2024 · control 08-AS-20210105122026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Iby Strong, conducted an unannounced Case Management Visit. LPA met with Administrator Kathryn Gabriel, and we discussed the purpose of the visit. Today's visit is in response to the self-reported death of Resident 1 (R1 - see LIC811 Confidential Names List). R1 passed away at the hospital, date of death: 3/25/2024 LPA conducted a wellness check at the facility, and no health or safety issues were identified. Residents observed appeared appropriate for the facility. Additional facility records were obtained on this date regarding R1's death. No deficiencies were cited or observed on this date. An exit interview was conducted. Administrator Kathryn Gabriel was provided a copy of their appeal rights (LIC9056 03/22), along with a copy of this report.the state’s words, verbatim · CDSS document, Apr 3, 2024

Allegation investigated: Licensee did not protect a resident from abuse.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a complaint investigation regarding the above allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Kathy Gabriel. It was alleged that Licensee did not protect Resident #1 (R1) from the abuse of Resident #2 (R2). CCLD’s investigation involved an un unannounced facility tour/welfare check, as well as collateral visits to other locations. The Department also reviewed pertinent administrative records and interviewed relevant facility staff and outside sources. [CONTINUED ON LIC 9099-C] Unfounded [CONTINUED FROM LIC 9099] Records, interviews, and LPA observation unanimously showed: Neither R1 nor R2 were residents of the CDSS-licensed facility, either at present or during the time frame of the complaint allegation. Based on records and interviews, the allegation against Licensee is Unfounded, meaning it was false, could not have happened, and/or is without a reasonable basis. We have therefore dismissed the allegation. An exit interview was conducted with the Gabriel, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 8, 2024 · control 08-AS-20240306153547