Solheim Senior Community

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted unannounced Case Management Annual Continuation visit to the facility. LPA met with Assistant Administrator, CEO, Wellness Manager and explained the reason for the visit. LPA informed Assistant Administrator that this visit was conducted to complete Required 1 year inspection initiated on 05/07/2025. During this visit at about 10:45a.m., LPA, Assistant Administrator, Wellness Manager toured the physical plant areas inside and outside to ensure there are no health and safety hazards in the facility. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Kitchen: is observed to be clean and sanitary. Sharps are stored in the kitchen area, inaccessible to residents at all times. Toxins, cleaning solutions, soap are locked in closet. Food: LPA observed at least two (02) days perishable and seven (07) days non-perishable food at the facility that is properly stored. Frozen foods are wrapped and stored properly as well. Food storage and preparation areas are clean. Laundry Room: LPA observed several washer and dryer machines located in the basement of the facility. LPA observed laundry room to be clean and clear from obstruction. Laundry soap, toxins and cleaning supplies are stored and locked within the laundry room, inaccessible to residents. During the tour LPA interviewed nine (09) out of eight-six (86) randomly selected residents and inspected their bedrooms and bathrooms at the time of this visit. Bedrooms were toured and observed to be clean and properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Linen storage was also checked and observed to have ample supply of clean linen, comforters, and towels in facility. Bathrooms were observed to be clean, sanitary and with necessary supplies. The appropriate grab bars Cont. on LIC 809-C Cont from LIC 809 and mats in the shower. Hot water temperature measured at a range of 110.3°F to 118.0°F and within the required range. Residents’ personal hygiene supplied are kept in their personal space. Towels and washcloths are not shared. Medication was observed to be locked in med rooms and inaccessible to residents in care. LPA observed main lobby area closed with a temporary wall due to alterations including drywalling, electrical work, flooring and wall removal. Surrounding Grounds The front grounds of the facility are well landscaped. All passageways and stairways were observed to be clear from obstruction. In the front entrance of the facility there is a covered porch area with benches for lounging. No bodies of water were observed on the premises. Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies observed cited on LIC809-D during the visit. Exit Interview Conducted / A Copy of the Report was provided to Assistant Administrator.the state’s words, verbatim · CDSS document, Oct 7, 2025

Allegation investigated: Staff do not maintain adequate records Lack of staff qualifications lead to residents health complications

At 9:45a.m., Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to conduct investigation and deliver the finding for the above noted allegations. LPA met with the Director of Nursing, Director Residential Health & Wellness and explained the reason for the visit. During initial visit, on 12/20/24 at 11:00a.m., LPA Alvizar-Ettima requested and received a copy of staff and residents’ roster. At approximately 11:20a.m., LPA conducted a tour of the facility, made observations and interviewed facility staff. Between 1:20p.m.- 2:50p.m. LPA interviewed nine (09) out of eight-six (86) residents in Assistant Living and Memory Care. During today’s visit at 11:25a.m., LPA Alvizar-Ettima reviewed six (06) randomly selected resident and seven (07) staff facility files. Between 1:05p.m. – 1:40p.m. interviewed three (03) CNA’s, one (01) caregiver, Resident Service Coordinator and Human Resources Director, asking questions relevant to the complaint. 1.) Staff do not maintain adequate records. Unsubstantiated It was alleged that staff loses facility records. Staff denied losing facility records for residents and staff. Staff indicated that all documents are always maintain in resident’s facility file and staff records are maintained separate. During interviews with nine (09) out of eighty-six (86) residents revealed that they have no issues with their records. When residents request their records staff provides copies of the documents to them. Residents’ interviews confirm that facility maintain adequate records. A review of facility resident records conducted on 05/07/25 supported the information provided by the staff and residents. Records contain their emergency Identification form with contact Information, Admission Agreement, Physician Report, Pre-Appraisal, Property Inventory/Belongings, Medication Administration Records and other miscellaneous records. Based on observation, interviews and documents review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. 2.) Lack of staff qualifications lead to residents’ health complications. It was alleged that due to unqualified staff residents developed pressure injuries. Staff interviews revealed that most caregivers are Certified Nurse Assistant (CNA’s). They have required qualifications to identify pressure injuries and report as required. Other staff confirmed that they received training regarding pressure injuries prevention and assistance. Interview with nine (09) out of eight-six (86) residents reveal that they did not have any pressure injuries. Staff revealed that at this time they have no residents with pressure injuries. A review of facility staff records, including staff training documents and an internal log identifying the frequency of staff assistance for the residents confirmed that staff received adequate training and residents are being assisted and supervised as required. Based on inspection, observation, interviews and records review, there is no sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. There were no deficiencies cited. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, May 7, 2025 · control 31-AS-20241220142604

Type of visit: Required - 1 Year

At 9:45 a.m., Licensing Program Analyst (LPA), Antonia Alvizar-Ettima conducted an unannounced annual inspection at the facility mentioned above. LPA met with the Director of Nursing & Director Residential Health & Wellness. LPA explained the reason for the visit. At 10:30a.m., physical tour was conducted with the Director of Nursing. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools. The facility is a two-story building with private and shared bedrooms, private bathrooms, kitchen, dining room, recreation rooms, common areas, patios, and outdoor areas. The facility has a Memory Care, Skilled Nursing, Residential Assisted Living and Independent Living. The facility has a fire clearance for one hundred and twenty-six (126) non-ambulatory residents, and a hospice waiver for seven (07) residents. The facility has multiple fire extinguishers located throughout the facility and all have a service tag dated of 01/17/2025. The smoke detectors are tested monthly and based on the LPA observations of the monthly inspection reports that shows results as passed for all apartments. The facility is equipped with fire sprinklers. Elevator: The facility has two (02) functioning elevators. LPA observed a posting for the facility’s emergency evacuation routes which was clearly labeled. Living, dining room and common areas: The facility has three (03) patio areas for residents in care. LPA observed the outdoor patio area for memory care and residential assisted living to have sufficient table and chairs for seating under a cover area. The facility has multiple dining areas throughout the facility that has a kitchenette area (counter, sink and refrigerator) inaccessible to residents. No toxins or hazardous materials stored in these areas. The facility has bookshelves located in the hallways which are accessible to residents for enjoyment. All common areas are appropriately furnished with tables and chairs and adequate lighting. LPA observed the areas to be clean and free from debris. LPA observed a storage closet on the second floor near the elevator to be storing an emergency disaster kits, wheelchairs and extra linens and hand and bath towels. LPA also observed additional closets for extra linens. Surrounding Grounds: The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. All passageways were observed to be clear from obstruction and no bodies of water were observed. Resident Files: LPA conducted a file review of six (06) randomly selected resident records to ensure compliance of licensing forms. Residents’ files appear to be complete and updated. Staff Files: LPA conducted a review of seven (07) staff records and they all have criminal record clearances and associated to this facility. Staff have current first aid and training documentation showing training completed. Administrator's certificate was observed to be current. Due to time constraints, LPA had to terminate the visit and will return on a later date to complete the Required - 1 Year inspection by inspecting kitchen, food, bathrooms, bedrooms, medication, laundry and interview residents. An exit interview was conducted. A copy of this report was provided to the Director Residential Health & Wellness. No deficiencies cited, exit interview conducted, copy of report signed and issued.the state’s words, verbatim · CDSS document, May 7, 2025

Type of visit: Required - 1 Year

At 9:45 AM, Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with the Administrator, Meg Pierce, and explained the reason for the visit. Physical tour was conducted with the Administrator and Maintenance Director and LPA observed the following: The facility is a two story building with private and shared bedrooms, private bathrooms, kitchen, dining room, recreation rooms, common areas, patios, and outdoor areas The facility has a Memory Care, Residential Assisted Living, and Skilled Nursing Unit. The facility has a fire clearance for one hundred and twenty-six (126) non-ambulatory clients, and a hospice waiver for seven (07). The facility has multiple fire extinguishers located throughout the facility to all have a service tag dated 01/01/2024. The smoke detectors are tested monthly and based on the LPA observations of the monthly inspection reports that shows results as passed for all apartments. The facility is equipped with fire sprinklers. Elevator: The facility had one functioning elevator. LPA observed a posting for the facility’s emergency evacuation routes which was clearly labeled. Kitchen: At 10:10 AM, LPA observed the kitchen to be clean and free from obstruction and inaccessible to residents. Appliances observed to be in good repair and functioning. The facility has a sufficient 7 days perishable and 2 days non-perishable food. The refrigerator (fresh fruit, vegetables, milk, bread, eggs, etc.) and the freezer (variety of meats, sandwich meat, desserts, and other dairy items) observed to be stocked and all properly labeled and stored. At 10:15 AM, LPA observed a two (02) rooms located near the entrance of the kitchen, one (01) to be storing a sufficient quantity of emergency food, the second to be storing brooms, mop buckets and cleaning supplies. Continue on LIC 809C Bedrooms: At 10:20 AM, LPA observed fourteen (14) random bedrooms that are equipped with private bathrooms. All bedrooms observed to be appropriately furnished with sufficient lighting. LPA observed appropriately bed linen and comforters on all beds. All bedrooms observed to be clean and clear from obstruction are single occupancy. The facility has public bathrooms located throughout the facility for visitors. Bathrooms: At 10:20 AM, LPA observed fourteen (14) private resident’s bathrooms and an additional public bathroom to be clean and clear from obstruction. LPA observed appropriate grab bars in shower and toilet area or a commode with handles around the toilet area. Bathrooms are stocked and equipped with soap and paper towels. At 10:22 AM, the hot water temperature measured at 118.4 degrees Fahrenheit. Medications: At 10:30 AM, LPA observed two (02) nursing stations on the first floor in the memory care unit, and on the second floor in the resident assisted living unit, to be storing medication carts, first aid kit with manuals, and resident records. Medication carts, refrigerators used for medication and specimen collection were observed to be locked and inaccessible to residents. LPA observed cupboards with medication baskets with resident names attached. Living, dining room and common areas: The facility has three (3) patio areas for residents in care. At 10:35 AM, LPA observed the outdoor patio area for memory care and residential assisted living to have sufficient table and chairs for seating under a cover area. The facility has multiple dining areas throughout the facility that has a kitchenette area (counter, sink and refrigerator) inaccessible to residents. No toxins or hazardous materials stored in these areas. The facility has bookshelves located in the hallways in the facility accessible to residents for enjoyment. All common areas are appropriately furnished with tables and chairs and adequate lighting. LPA observed the areas to be clean and free from debris. At 10:40 AM, LPA observed a storage closet on the second floor near the elevator to be storing an emergency disaster kits, wheelchairs and extra linens and hand and bath towels. LPA also observed additional closets for extra linens. Laundry Room: At 10:45 AM. LPA observed the laundry room located in the basement to be inaccessible to residents clean and clear from obstruction. Extra cleaning supplies, laundry detergents, and other items were stored in the basement/laundry room. Continue on LIC 809C At 10:20 AM, LPA tested the call system in Room #215 to be functional. Staff responded to the call within thirty (30) seconds. Between 1:00 PM to 2:30 PM, LPA reviewed records of nine (9) resident and six (6) staff. Resident and staff records appeared to be complete and updated. No deficiencies cited, exit interview conducted, copy of report signed and issued.the state’s words, verbatim · CDSS document, Jul 23, 2024