A Long History of Success

Veterans Village of San Diego’s (VVSD) motto is “Leave No One Behind.” It’s a noble but lofty goal.

When I, as a former soldier, read those words, I immediately think of the Ranger Creed, which reads in part, “I will never leave a fallen comrade to fall into the hands of the enemy…” For soldiers, those are more than words; it’s a solemn promise, one that will be kept if at all humanly possible.

Veterans Village of San Diego has a noble mission, to help homeless and addicted veterans reclaim their lives by offering housing, mental health counseling, substance abuse treatment, and employment training services. Their enemies include substance abuse, homelessness, and mental health issues. Basically, anything that would challenge a vet from becoming a productive member of society. For over forty years, they have been successful in this mission and have helped numerous former servicemembers. They’ve received multiple accolades on local and national levels, and the facility was even held up as a model of success on 60 Minutes.

I should take a hard break right now and state that although it has been endorsed by the Veterans Administration (VA), it is NOT a VA healthcare facility. It’s a privately run non-profit.

I’m writing this piece today because Veterans Village has a problem. The once highly respected facility seems to have become a potential danger to those veterans who go there at their lowest points looking for help. By many accounts, the facility is dangerously understaffed, drug use is rampant, and living conditions are unsafe. The facility has received six complaints that are currently under review by the California state healthcare department. Two lawsuits were filed against them in the past year, and an additional two complaints were sent to the VA inspector general’s office as recently as April.

It’s not just that the quality of the food has declined (which it has) or that facility is understaffed (which it is). There have been numerous overdoses in recent months, one of which was caused by fentanyl and resulted in the death of the client. That matter has been referred to the DEA, and they are currently investigating the case.

A SEAL is Down

Nathan “Lalo” Roberti graduated BUD/S Class 247, attended SQT followed by Airborne School, and was assigned to SEAL Team 10. He says he was supposed to be on the ill-fated Black Hawk code named Turbine 33, which was shot down as part of a quick reaction force during Operation Redwings trying to rescue fellow SEALs in contact on Sawtalo Sar. Three SEALs on the ground and all of the Army Night Stalkers and SEALs on Turbine 33 died that day.

Roberti developed PTSD and substance abuse problems following his time in service, leading to a series of arrests. In 2013 a Veterans Treatment Court placed him at Veterans Village of San Diego for treatment. He graduated from the program, started a business in New York, and relapsed. He ended up in Long Beach, California, where he was arrested again on assault charges. His addiction reared its ugly head once more, and he was homeless for two years.

In a statement to the Treatment Court, Roberti wrote the following:

“Being homeless was both a blessing and a curse; my ego and my shame were peeled away like the layers of an onion and I finally hit what I believe to have been my absolute bottom.”

He pleaded guilty to stealing a U-Haul truck in September of 2021 and was accepted back to Veterans Treatment Court. As a condition of his release from jail, the Court required that he maintain his sobriety. In February of 2022, Roberti applied to the substance abuse treatment program at Veterans Village.

In a letter penned on April 3, 2022, the former SEAL wrote, “I’m a work in progress. I know I’m a 40-year-old man now, but I know I can do this. I am doing it now, and I’ll continue to fight for my life and the lives of those around me who I love and cherish deeply.” He continued, “I’m starting to like to be alive, and that’s a good thing for me because I haven’t felt that way in many years.” 

The Veterans Village that treated Roberti was not the same one he attended in 2013. Drug use was rampant, there was a strong criminal element present, staffing levels were sub-optimal, and the leadership of the facility was turning a blind eye to these shortcomings.

A mere two weeks after writing that latter, Nathan Roberti overdosed on opioids while at VVSD. He was found unresponsive in a bathroom, revived with Narcan, and taken to a local hospital for treatment. There is where his trail ends. Roberti disappeared from the hospital, and a warrant was issued for his arrest. He is on the run.

Just One Story

His is but one story of how today, VVSD is failing veterans. The program is now so bad that San Diego probation officials have taken the highly unusual step of removing their clients from the facility and stopping future referrals. It’s really saying something when these professionals feel the treatment center would pose more of a harm than a help to them. And why is that?

Staff and patients don’t feel safe at Veterans Village. The number of times the police had to report to the facility has more than doubled since 2021. Last year, a staff member was caught selling methamphetamine and exposing himself at the rehab center. There was no word on whether he was doing both at the same time or not. That guy was understandably fired.

Residents and former residents are quick to say how easy it is to acquire drugs in the rehab facility. One is quoted as saying, “It’s easier to get heroin here than Advil.” The current program has been described as a “minefield” for those with addiction. Methamphetamine, fentanyl, and heroin seem to be the drugs of choice. The clients who are trying to get clean reportedly are being offered these drugs on a regular basis by others in the rehab program. One man reported trying meth for the very first time when his roommate offered it to him.

This is clearly the opposite of what you want to see in such a facility where people are fighting for sobriety.

So, how did things get this bad?

As with most problems on this scale, the cause isn’t just one thing; it’s multifactorial. Initially, one always looks to leadership to keep order. A new CEO took the reigns at Veterans Village in 2020, the first non-veteran to do so. Speaking as a veteran, I can say from personal experience that sometimes veterans tend to trust non-veterans less than they otherwise would when they take over an important leadership role.

When investigative reporters from inewsource began catching wind of what was going on inside Veterans Village, their human resources department put out a media policy to all employees stating that they were forbidden to speak with reporters. Hmmmm…curious timing there. All staff was expected to sign and date the policy; failure to do so could lead to disciplinary actions up to and including termination. Not that they can afford to lose any more employees; at last count, there were 34 openings at a place that used to have 120 employees.

As might be expected, when addressing this plethora of allegations Akilah Templeton, the chief executive officer at Veterans Village, reminded the press that drug use is not permitted at the facility. Honestly, what else did we expect her to say? She went on to note that despite staffing shortages, services have not suffered as a result, and they continue to offer high-quality care. Again, many would beg to differ, but CEOs must espouse the company line.

Mike Workman, a spokesman for The County of San Diego’s Behavioral Health Services (BHS) Department, says that BHS is aware of the concerns of overdoses, death, drug abuse, and crime at the facility but comments that these issues “are not unique to VVSD in light of the services provided.” No, sir, they are not, but I would go as far as to say they were not desirable and that everything possible should be done to eliminate them.

To be fair, Mr. Workman did follow up with, “We have worked very closely with them to develop a plan to address concerns related to VVSD’s staffing/vacancies, while also identifying opportunities for more thorough documentation and communication protocols.” Staffing, communications, and documentation… that’s a start, but it doesn’t seem to strike at the root of the problem.

Residents and staff had a better idea; they wanted to bring in drug dogs and conduct unannounced campus-wide searches for drugs and other contraband. But those searches never materialized.

Money, Damned Money

I’ve always said if you look hard enough at most problems, you are going to find a monetary element in there somewhere. In 2018 VVSD started accepting Drug MediCal funding. Drug MediCal is a treatment funding source for eligible MediCal members. MediCal is California’s Medicaid program that provides medical services to low-income residents of the state for little or no cost. Dig a little deeper, and one discovers that Medi-Cal reimburses treatment facilities at about twice the amount the VA does. Simply put, they get more money by accepting more MediCal patients.

In the past year, despite a significant staffing shortage, Veterans Village quietly doubled its number of MediCal beds from 56 to 101. This is out of a licensed 224 beds. When the facility started accepting MediCal payments, they also began accepting non-veterans as patients. I can see how this might cause some uneasiness in a facility that used to have a 100% veteran population. We tend to understand each other’s backgrounds to some extent and what they’ve been through.

Interestingly, VVSD makes no note of Drug MediCal funding or the acceptance of non-veterans on its website. I invite you to check it out for yourself. It does, however, mention veterans multiple times and says that they are a “state-licensed drug and alcohol rehabilitation center that serves male and female military veterans.” This is the truth, but not the whole truth. I wonder why the omission? Could it be because donors might not be so eager to give, knowing the facility now accepts non-veterans and more MediCal funding? Perhaps.

The Fix

I’m not arrogant enough to think I can fix all of the problems of the world with a few keystrokes from my home office. I do, however, have some ideas on what the powers that be at VVSD might want to consider to bring their level of care and assistance back to where it used to be. Perhaps, for whatever reason, these ideas cannot be implemented at this specific facility. I’m sure that will be duly noted in the comments. I’ve worked in healthcare for several years, both on the military and civilian side, and I realize the very real roadblocks that exist. However, for every roadblock, there are two paths to excellence.

• Invite SAMHSA to look at the problem: SAMHSA is the Substance Abuse and Mental Health Services Administration. They fall under the umbrella of the Department of Health and Human Services. The state of California falls into Region 9. Someone should really contact the Regional Administrator and ask her what her take is on the situation at Veterans Village. If it’s not her lane, I’m sure she can tell you whose lane it is.
• Have the VA Office of the Inspector General inspect the entire facility: I know they are already looking at two specific situations there, but they need to look at the facility as a whole, and that look needs to include lengthy discussions with residents, former residents, and staff. I can hear the voices in the background piping up now, “But sir, we can’t do that.” I would have never gotten anything done if I had stopped every time I heard that. Yes, you can. Do it.
• Plant an undercover client or two: I hate to go all Secret Squirrel on them, but in this case, it almost seems like a necessity to get an accurate and real-time picture of what is going on in the facility. The covert client does not have their own agenda; they are just there to document and report their findings. “Report to Whom?” you are thinking. Good question. Convene a group made up of federal and state inspectors responsible for ensuring the orderly operation of the facility. Make it a multi-disciplinary group.
• Involve the California Department of Health Care Services: According to their website they have sole authority to license facilities providing residential nonmedical services to eligible adults who are recovering from problems related to alcohol or other drug (AOD) misuse or abuse. No licensure equals no funds equals big motivations to fix problems for real.
• Make VVSD a Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accredited facility: Briefly, the Joint Commission, as they are called, is a non-profit organization that inspects healthcare facilities using best practice guidelines. If there are any problems with your facility, their inspectors will uncover them, and the facility must develop an action plan to fix the issue. And believe me, they will follow up before giving your facility accreditation. Joint Commission accreditation is a big deal. It’s the gold standard for quality in healthcare. For one hospital system I worked in, it meant the difference between getting federal funds if we passed accreditation (we are talking over 100 million dollars here) and losing that money. Having and maintaining JCAHO accreditation would keep leadership on their toes to address quality issues in a timely manner.

To me, the many problems of VVSD are fixable, but it won’t be easy. It will take time and lots and lots of communication. Still, it must be done. We owe it to our veteran community to give them the very best healthcare possible in every type of facility. When a vet reaches out for help, they should be secure in the knowledge they are going to get that help. If they are not confident of that fact, they will likely not reach out at all and continue to suffer in silence, or worse.

Attribution: This piece would not have been possible without the extremely hard work and dedication of a team of writers and investigators from inewsource. They have done a deep dive on this and continue to follow up on the story. The original source material for much of my story can be found here. It is definitely worth a read.