Inspection Report Summary
Most inspections found no deficiencies, showing the facility was generally clean, well-maintained, and compliant with safety, health, and infection control standards. Several annual visits between 2021 and 2025 were free of any citations, reflecting a strong record over time. The most recent report from October 7, 2025, did cite two deficiencies related to construction work done without the required building permit and inadequate maintenance procedures during that construction, which posed potential health and safety risks. These issues were isolated to the construction area and did not involve resident care or infection control. Overall, the facility’s condition appears stable with a recent minor setback linked to building compliance rather than ongoing operational problems.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
95% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
68% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Dec 18, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident dignity, safety, care, infection control, nutrition, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and respect, inadequate personal hygiene care, improper infection control practices, failure to maintain safe and appetizing food service, improper use and monitoring of medical equipment, inadequate call light accessibility, and failure to implement an effective antibiotic stewardship program. Several residents were observed with unclean clothing, delayed assistance with activities of daily living, and unsafe environmental conditions such as open dumpster lids.
Deficiencies (13)
Failure to promote dignity and respect for residents, including unclean clothing and inappropriate staff communication.
Failure to maintain a safe, clean, comfortable, and homelike environment, including noise disturbances from staff radios.
Failure to provide care and assistance for activities of daily living, including grooming and personal hygiene.
Failure to accurately monitor fluid intake for a resident on fluid restriction, risking fluid overload.
Failure to implement pressure ulcer prevention measures, including incorrect settings on low air loss mattresses.
Failure to prevent accidents by not positioning resident's head of bed upright during meals, risking aspiration.
Failure to ensure food is palatable, attractive, and served at safe and appetizing temperatures.
Failure to follow proper food storage and labeling practices, risking foodborne illness.
Failure to ensure garbage dumpsters lids remained closed, risking vermin infestation.
Failure to maintain accurate and complete medical records, including medication monitoring orders.
Failure to ensure infection prevention and control practices, including proper storage and labeling of respiratory equipment.
Failure to implement an antibiotic stewardship program, including lack of culture and sensitivity testing and unclear antibiotic indications.
Failure to ensure call lights were within reach of residents in bathrooms and rooms.
Report Facts
Weight: 113
Weight: 103
Fluid restriction: 1600
Temperature: 125
Temperature: 120
Temperature: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Staff Development | Director of Staff Development | Interviewed regarding dignity and call light issues |
| Licensed Vocational Nurse 5 | Licensed Vocational Nurse | Interviewed regarding noise from staff radios |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Interviewed regarding addressing residents with labels and noise disturbance |
| Licensed Vocational Nurse 2 | Licensed Vocational Nurse | Interviewed regarding fingernail hygiene and dignity issues |
| Registered Dietitian | Registered Dietitian | Interviewed regarding fluid restriction and food temperature |
| Infection Prevention Nurse | Infection Prevention Nurse | Interviewed regarding infection control practices |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding dumpster lids and waste management |
| Director of Nursing | Director of Nursing | Interviewed regarding infection control and fluid restriction monitoring |
| Certified Nursing Assistant 6 | Certified Nursing Assistant | Interviewed regarding call light accessibility |
| Director of Staff Development | Director of Staff Development | Interviewed regarding call light accessibility |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Nov 14, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care and safety at Solheim Senior Community.
Findings
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with poor mobility and balance, resulting in a fall with injury. Additionally, the facility failed to provide adequate supervision to prevent accidents, leading to the resident sustaining a fracture and head trauma after a fall in the shower room.
Deficiencies (2)
Failure to develop and implement a complete care plan that meets all the resident's needs, including measurable objectives and timetables.
Failure to ensure the nursing home area is free from accident hazards and to provide adequate supervision to prevent accidents, resulting in a resident fall with injury.
Report Facts
Residents affected: 1
Laceration size: 1.5
Fall incident date: Nov 2, 2025
Duration of neck brace use: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding resident care and fall incident |
| Director of Rehabilitation | Director of Rehabilitation | Provided assessment of resident's mobility and care needs |
| MDS nurse | MDS nurse | Interviewed about resident's care plan and mobility needs |
| Registered Nurse 1 | Registered Nurse | Responded to fall incident and documented progress notes |
| Certified Nurse Assistant 1 | Certified Nurse Assistant | Left resident unattended leading to fall |
| Certified Nurse Assistant 2 | Certified Nurse Assistant | Provided information on resident care and shower chair limitations |
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse | Observed resident after fall and verified incident details |
Inspection Report
Annual Inspection
Census: 86
Capacity: 126
Deficiencies: 2
Date: Oct 7, 2025
Visit Reason
The inspection was an unannounced Case Management Annual Continuation visit conducted to complete the required 1-year inspection initiated on 2025-05-07.
Findings
The facility was generally found to be clean, sanitary, and safe with proper storage of food, medications, and cleaning supplies. Resident bedrooms and bathrooms were clean and properly furnished. However, deficiencies were cited related to construction alterations without a required building permit and lack of maintenance provisions during construction, posing potential health and safety risks.
Deficiencies (2)
Main lobby area closed with a temporary wall due to alterations including drywalling, electrical work, flooring and wall removal without providing a required building permit.
Failure to provide maintenance services and procedures for safety and well-being of residents, employees, and visitors during construction.
Report Facts
Perishable food storage duration: 2
Non-perishable food storage duration: 7
Hot water temperature range: 110.3
Hot water temperature range: 118
Number of residents interviewed: 9
Plan of Correction due date: Oct 21, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted the inspection and authored the report |
| Naira Margaryan | Licensing Program Manager | Oversaw the licensing program related to this inspection |
| Samuel Oden | Chief Executive Officer (CEO) | Interviewed during the inspection and referenced in deficiency observation |
| Mike Gonzalez | Assistant Administrator | Interviewed during the inspection and referenced in deficiency observation |
| Shelia Lucas | Wellness Manager | Interviewed during the inspection |
Inspection Report
Annual Inspection
Census: 86
Capacity: 126
Deficiencies: 0
Date: May 7, 2025
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements at the facility.
Findings
The facility was found to be well-maintained with no deficiencies cited during the inspection. Safety equipment such as fire extinguishers and smoke detectors were properly maintained, and resident and staff files were complete and up to date. The inspection was not fully completed due to time constraints and will be continued at a later date.
Report Facts
Fire extinguishers service date: Jan 17, 2025
Hospice waiver capacity: 7
Resident files reviewed: 6
Staff files reviewed: 7
Elevators: 2
Patio areas: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marie Garnett | Director of Nursing | Met with Licensing Program Analyst during inspection |
| Mike Gonzalez | Director Residential Health & Wellness | Met with Licensing Program Analyst during inspection |
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Routine
Deficiencies: 9
Date: Oct 11, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care, medication administration, infection control, food safety, and other health and safety standards.
Findings
The facility was found deficient in multiple areas including failure to develop and implement comprehensive care plans, medication administration errors including expired and unlabeled medications, failure to follow infection control protocols such as gown use during wound care and medication administration via gastrostomy tube, improper food handling practices including unlabeled and expired food items, and failure to maintain proper documentation and monitoring of psychotropic medication use.
Deficiencies (9)
Failed to develop a comprehensive, resident-centered care plan and implement care plan interventions for a resident's actual fall.
Failed to address significant unplanned weight loss in a resident in accordance with facility policy.
Failed to administer correct oxygen level as ordered by physician for a resident.
Failed to provide pharmaceutical services including administering expired medication, missing medication doses, and expired medications stored in medication rooms.
Failed to ensure psychotropic medication was used appropriately with specific target behavior and monitoring.
Medication error rate during medication pass observation was 7.1%, exceeding the 5% threshold.
Failed to ensure drugs and biologicals were labeled correctly and stored properly, including expired medication and incorrect medication route labeling.
Failed to follow proper food handling practices including unlabeled food items, expired food, and dented soda cans in storage.
Failed to implement infection prevention and control program properly, including failure to wear gowns during wound care and medication administration for residents on enhanced barrier precautions.
Report Facts
Medication Administration Error Rate: 7.1
Weight loss percentage: 5.56
Expired medication count: 6
Bread packs expired: 35
Medication expiration date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Observed preparing and administering expired medication and medication via gastrostomy tube with incorrect labeling. |
| MDS Nurse | Minimum Data Set Nurse | Provided statements regarding care plan deficiencies, medication errors, and infection control issues. |
| TN 1 | Treatment Nurse | Observed not wearing gown during wound care treatment for multiple residents. |
| CNA 4 | Certified Nurse Assistant | Observed assisting with wound care without wearing gown. |
| LVN 3 | Licensed Vocational Nurse | Reported expired medications mixed in medication room. |
| LVN 4 | Licensed Vocational Nurse | Verified psychotropic medication order issues for Resident 53. |
| ADON | Assistant Director of Nursing | Provided information on infection control policies and psychotropic medication monitoring. |
| IPN | Infection Preventionist Nurse | Confirmed need for PPE during wound care and infection control. |
| CNA 5 | Certified Nurse Assistant | Reported lack of PPE signage and gown use during wound care assistance. |
Inspection Report
Annual Inspection
Census: 82
Capacity: 126
Deficiencies: 0
Date: Jul 23, 2024
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements and facility conditions.
Findings
The facility was found to be clean, well-maintained, and compliant with safety and health standards. No deficiencies were cited during the inspection.
Report Facts
Resident records reviewed: 9
Staff records reviewed: 6
Fire clearance capacity: 126
Hospice waiver capacity: 7
Hot water temperature: 118.4
Inspection start time: 945
Inspection end time: 1510
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Meg Pierce | Administrator | Met with Licensing Program Analyst during inspection |
| Huma Rahimi | Licensing Program Analyst | Conducted the inspection |
| Nichelle Gillyard | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Routine
Deficiencies: 12
Date: Oct 5, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, food safety, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to inform residents about ancillary care, inadequate accommodation of resident needs, failure to notify physicians of significant weight loss, incomplete baseline and comprehensive care plans, delays in toileting assistance, improper pressure ulcer prevention measures, nutritional intervention failures, medication administration errors, storage of expired medications and supplies, food safety violations, and infection control breaches.
Deficiencies (12)
Failed to ensure Resident 19 was informed in advance about ancillary care and the professionals providing care.
Failed to reasonably accommodate the needs and preferences of residents, including shower assistance and call light accessibility.
Failed to notify the physician for severe weight loss and Registered Dietician recommendation for Resident 5.
Failed to develop a baseline care plan within 48 hours of admission for Resident 221.
Failed to revise the comprehensive care plan for Resident 36 to include care for weakness.
Failed to provide timely assistance with toileting for four residents, resulting in frustration and potential skin breakdown.
Failed to ensure low air loss mattresses were set to correct pressure settings according to resident weight for three residents.
Failed to implement and modify nutritional interventions to maintain acceptable nutritional status for Residents 5 and 60.
Medication administration errors with a 30.77% error rate for Resident 64, including late administration of seven medications.
Failed to properly store and dispose of expired medications and supplies in medication storage rooms.
Failed to label foods with item names, open dates, and expiration dates; failed to discard expired foods; failed to clean ice machine; and failed to maintain proper air gap for kitchen drainage pipe.
Failed to follow infection control measures in the kitchen and oxygen administration, including contaminated kitchen items on the floor and oxygen tubing touching the floor.
Report Facts
Medication errors: 8
Medication error rate: 30.77
Weight loss: 19
Weight loss percentage: 14.29
Medication administration time: 10.57
Call light wait time: 45
LAL mattress setting: 400
Expired items count: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 4 | LVN | Stated oxygen tubing should not touch floor; medication administration and LAL mattress setting observations |
| Registered Nurse 1 | RN | Confirmed oxygen tubing infection control issue and medication administration timing concerns |
| Director of Nursing | DON | Discussed medication administration timing, notification of physician for weight loss, and expired medication storage |
| Assistant Director of Nursing | ADON | Verified expired medications and supplies in medication room |
| Licensed Vocational Nurse 1 | LVN | Discussed LAL mattress settings and treatment supplies storage |
| Director of Dining Services | DDS | Discussed food labeling, expired food disposal, and ice machine cleaning |
| Infection Preventionist Nurse | IPN | Discussed infection control concerns in kitchen and food safety |
| Licensed Vocational Nurse 3 | LVN | Administered medications late to Resident 64 |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jun 15, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pressure ulcer care standards and to assess the proper use and monitoring of the Low Air Loss Mattress for residents at risk of pressure ulcers.
Findings
The facility failed to input the correct setting on the Low Air Loss Mattress for one sampled resident, which could potentially lead to the development of a pressure ulcer. The physician's orders and treatment records did not specify mattress adjustments according to the resident's weight, and staff had inconsistent understanding of mattress setting requirements.
Deficiencies (1)
Failed to input the correct setting on the Low Air Loss Mattress for one resident, potentially leading to pressure ulcer development.
Report Facts
Resident weight: 128
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | LVN | Observed incorrect mattress setting and stated it should be adjusted according to resident's weight |
| Licensed Vocational Nurse 2 | LVN | Stated mattress only needs to be firm and does not need adjustment according to resident's weight |
| Director of Nursing | DON | Stated licensed nurses and CNAs should check mattress settings each time they care for the resident and documentation should be signed daily |
Inspection Report
Annual Inspection
Capacity: 126
Deficiencies: 0
Date: Jun 9, 2022
Visit Reason
The inspection was an unannounced one-year required infection control visit to evaluate compliance with infection control and facility safety standards.
Findings
The facility was found to be clean, well-maintained, and compliant with infection control and safety requirements. No deficiencies were cited during the inspection.
Report Facts
Fire clearance capacity: 126
Hospice waiver capacity: 7
Food supply duration: 7
Food supply duration: 2
Number of bedrooms inspected: 11
Number of bathrooms inspected: 11
Water temperature range: 110.3
Water temperature range: 120
Number of nursing stations observed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Meg Pierce | Executive Director | Met with Licensing Program Analysts during inspection |
| LaQueena Lacy | Licensing Program Analyst | Conducted inspection and signed report |
| Gary Tan | Licensing Program Analyst | Conducted inspection |
| Naira Margaryan | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 33
Capacity: 126
Deficiencies: 0
Date: Jun 15, 2021
Visit Reason
Licensing Program Analyst Martina Berry conducted a required annual visit at the facility to evaluate compliance and infection control measures.
Findings
The facility was found to have no deficiencies cited. All residents and staff were fully vaccinated, infection control procedures were in place and followed, and the facility maintained proper sanitation and PPE protocols.
Report Facts
Resident census: 33
Total capacity: 126
Inspection duration: 2.25
Medication supply duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Meg Pierce | Administrator | Met during entrance and exit interviews |
| Marie Garnett | Wellness Director | Met during entrance and exit interviews |
| Martina Berry | Licensing Program Analyst | Conducted the inspection |
| Cassandra Harris | Licensing Program Manager | Named in report header and signature |
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