Map showing the location of VICTORIA POST ACUTE CARE in EL CAJON, California
654 S. ANZA, EL CAJON, CA, 92020

Overall Score

CMS Five-Star Quality Rating
4/5Above averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • CaliforniaAbove 57% of peers1,154 rated homes · average 3.2★
  • San Diego CountyAbove only 31% of peers81 rated homes · average 3.9★
  • United StatesAbove 61% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point3★+0.2 vs CA avg
  • StaffingCan add or remove a star4★+0.9 vs CA avg
  • Quality measuresCan add or remove a star5★+0.9 vs CA avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles3★Above only 44% of peersCA avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover4★Above 60% of peersCA avg3.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 57% of peersCA avg4.1★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff4.07hrsAbove only 32% of peersCA avg4.51Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.47hrsAbove only 47% of peersCA avg0.65Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better57%Above only 7% of peersCA avg38%RN turnover36%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$0Above only 45% of peersCA avg$26,970Fines · denials0 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
37citations
10inspection dates
1actual harm (G–I)
0immediate jeopardy (J–L)
Sep 4, 2025most recent

Citations by monthDec 2019 – Sep 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Sep 4, 20251 citationCycle 1worst D · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Oct 4, 2025
Jul 31, 20251 citationCycle 1worst D · no actual harm
  1. F627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.Resident RightsD · isolatedCorrected Aug 22, 2025
Sep 13, 202410 citationsCycle 1worst F · no actual harm
  1. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Oct 10, 2024
  2. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Oct 10, 2024
  3. F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy ServiceD · isolatedCorrected Oct 10, 2024
  4. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Oct 10, 2024
  5. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Oct 10, 2024
  6. F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationD · isolatedCorrected Oct 10, 2024
  7. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Oct 10, 2024
  8. F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsD · isolatedCorrected Oct 10, 2024
  9. F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningD · isolatedCorrected Oct 10, 2024
  10. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Oct 10, 2024
Aug 30, 20241 citationCycle 2worst D · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Sep 20, 2024
Jul 24, 20242 citationsCycle 2worst D · no actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 15, 2024
  2. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 15, 2024
Apr 17, 20241 citationCycle 2worst D · no actual harm
  1. F624Prepare residents for a safe transfer or discharge from the nursing home.Resident RightsD · isolatedCorrected May 3, 2024
Jan 26, 20242 citationsCycle 3worst D · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Feb 19, 2024
  2. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Feb 19, 2024
Jun 9, 20231 citationCycle 3worst D · no actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 12, 2023
Sep 28, 202215 citationsCycle 2worst G · actual harm
  1. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Nov 16, 2022
  2. F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Resident RightsD · isolatedCorrected Nov 16, 2022
  3. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsG · isolatedCorrected Nov 16, 2022
  4. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Nov 16, 2022
  5. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Nov 16, 2022
  6. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Nov 16, 2022
  7. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Nov 16, 2022
  8. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Nov 16, 2022
  9. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Nov 16, 2022
  10. F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Pharmacy ServiceD · isolatedCorrected Nov 16, 2022
  11. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Nov 17, 2022
  12. F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.AdministrationD · isolatedCorrected Nov 16, 2022
  13. F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationE · patternCorrected Nov 16, 2022
  14. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Nov 17, 2022
  15. F881Implement a program that monitors antibiotic use.Infection ControlD · isolatedCorrected Nov 16, 2022
Dec 12, 20193 citationsCycle 3worst D · no actual harm
  1. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Jan 7, 2020
  2. F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Nutrition and DietaryD · isolatedCorrected Jan 7, 2020
  3. F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Nutrition and DietaryD · isolatedCorrected Jan 7, 2020

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined4.07hrsAbove only 32% of peers−0.44 vs CA avg
  • Registered nursesRN hours only0.47hrsAbove only 47% of peers−0.18 vs CA avg
  • Licensed practical nursesLPN hours1.22hrs
  • Nurse aidesCNA hours2.38hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.81hrs
  • California average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better57%Above only 7% of peersCA avg 38%
  • RN turnoverRegistered nurses only36%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy120 certified beds · ~112 residents a day93%Above 64% of peersCA avg 88%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $0In fines
  • 0Fines
  • 0Payment denials
  • $26,970CA avg in fines
Above only 45% of peersFewer fines than 45% of rated homes in California

Actions on record

No fines or payment denialsNothing on record in the current reporting window. California facilities average 1.3 penalties.

Ownership

As filed with CMS

Structure

Ownership type
For profit - Corporation
Chain
The Ensign Group324 facilities in the chain3.2★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Flagstone Healthcare South LLC
Indirect owners (5%+)
  • The Ensign Group INC
Operational or managerial control
  • Lincare INC
  • Edward Dove
  • Anthony Fam
Corporate directors
  • Adam Willits
Corporate officers
  • Soon Burnam
  • Chad Keetch
  • Katherine Oh
  • Ami Sato

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 555804 · 654 S. ANZA, EL CAJON, CA, 92020.
  • Percentiles compare this facility with every rated nursing home in California and San Diego County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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