State moved to revoke VVSD license after April inspection revealed more violations

State officials moved to revoke the substance abuse treatment license of Veterans Village of San Diego because it found several new licensing violations during an inspection in April, according to a formal accusation filed last week.

Those new findings violated the terms of a settlement agreement between the state and VVSD that was signed in March 2023, causing the organization’s license to be placed on probationary status.  

The state Department of Health Care Services, which oversees licensing for substance abuse programs, said that an inspection of the nationally known VVSD in April revealed seven violations of state regulations and VVSD policies. 

The violations concerned oversight of medications residents receive, not conducting drug screenings as required in some instances and not adhering to VVSD policies allowing residents to leave the Pacific Highway campus.

Notably, the unredacted portions of the accusation do not specifically say the license is being pulled for any of the seven deaths DCHS said clients of VVSD have suffered since the start of 2022. 

The 25-page, heavily redacted accusation alleged that VVSD “demonstrated conduct that is inimical to the health, morals, welfare and/or safety of individuals receiving service” from the organization. 

Some of the violations had been cited in previous inspections. Those were resolved in a settlement agreement the department signed with VVSD in March 2023. 

That deal, which stemmed from a series of investigations into several deaths in 2022 and other complaints, resulted in VVSD’s license being placed on probationary status for 18 months.

Part of the agreement noted that any additional “Class A” violations – the most serious breach of regulations that are seen to pose an imminent danger to residents – or any violations that related to failure to monitor residents would be cause to end probation and revoke the license.

VVSD can appeal the revocation order. The state issued a temporary suspension order prohibiting the organization from offering substance abuse services effective Monday.

The move against the license last Thursday forced San Diego County, which contracts with VVSD to provide services under the state Drug Medi-Cal program, to move out 74 clients who were living there.

By Wednesday, the county said the clients had been moved to other treatment programs, provided housing or self-discharged. 

State regulators conducted an unannounced visit to VVSD on April 10, apparently in response to an overdose death in March of Jeffrey Connors Jr., who died after taking a fatal dose of fentanyl. 

That inspection revealed deficiencies cited in the revocation order that include: 

• Repeatedly violating policies governing when residents do not take medications as needed. The state said VVSD did not complete and forward daily audits detailing if someone was taking their medication. The revocation order references the “Decedent’s” – likely Connors, though the name is blacked out – own files, and said that VVSD did not take “adequate steps to intervene when Decedent repeatedly failed to follow their medication regime.”
• Failing to monitor and track client medications. A separate violation says the organization did not properly document when client medications were destroyed. 
• The state alleged VVSD repeatedly violated its policies for giving residents passes to go off-site.
• Not conducting required urinalysis drug screening of clients. The accusation said that on different occasions residents were selected to provide a sample but never did. The staff did not follow up. 
• Not taking a urinalysis sample from “Decedent,” again likely Connors, when he returned to the site. The accusation says that VVSD policy classifies someone who returns from being off-site but does not follow a sign-in procedure as AWOL and subject to a drug test. 

The accusation said that about a month after the inspection in a phone interview with a VVSD staff member, the staff person acknowledged that the organization “has had an ongoing issue with security guards, who are contracted, at the front desk not recording when a client arrives at Program.”

DCHS said that the failure to follow policies regarding medication destruction and inventorying, drug screening, and off-premises travel by clients were the same cited in an earlier “notice of deficiency” filed in October 2022. 

VVSD has refused to respond to questions from inewsource, which has published a series of stories about problems at VVSD over the past two years, and this week declined to provide a copy of a statement on the state’s licensing action, though it was distributed to other media. 

In the statement, obtained by inewsource, vice president of communications and development Kimberley Monday said the organization was shocked by the state’s action. 

“We are deeply concerned by the State’s swift and severe decision, especially during a time when homelessness is on the rise, fentanyl misuse is escalating, and economic uncertainty is widespread,” the statement said. 

“This decision has come as a profound shock to our team, who have consistently worked to meet every request aimed at enhancing the quality of our programs and services. The impact on our staff and the clients we serve is deeply distressing.”

She also reiterated complaints from VVSD leaders, calling the coverage “misleading and inaccurate.” 

“We are troubled by what seems to be an orchestrated attempt by inewsource to manipulate the narrative and incite action against us,” the statement said.

The most recent inewsource story was published July 30 and revealed for the first time the probationary agreement with the state and the Connors death. The state’s visit that triggered the revocation action occurred months before on April 10. 

Jamie Self, managing editor for inewsource, defended the reporting. “We have given Veterans Village leadership numerous opportunities, before and after publication, to respond to our reporting, which has been rigorously fact-checked. We stand by our reporting,” Self said in a statement.

The VVSD statement said that programs specifically serving veterans remain operating and are not affected by the licensing action. 

Residents at VVSD are funded from several sources, including the Veterans Administration and the Drug Medi-Cal program. A VA spokesman said last week there are 48 vets receiving substance abuse treatment out of 141 total who are receiving VA support.

They will be able to stay at the site and receive treatment elsewhere, and veterans living there who do not receive substance abuse services can remain. The VA said, however, that it is halting all new admissions.