Health inspection·January 27, 2026

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor 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. Based on observations, interview and record review the facility failed to provide a safe, sanitary environment for five Residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5) in a census of 159 when flies were found in the rooms of all five residents. These findings compromised the residents' right to receive care in a clean, safe, and dignified setting, and increased the risk for infection, cross contamination, and created an unsanitary environment. Findings:Resident 1 was admitted to the facility in mid-2024 with diagnosis which included major depressive disorder, anxiety disorder, muscle weakness, and inability to walk.Resident 2 was admitted to the facility in late 2025 with diagnosis which included major depressive disorder, urinary tract infections, and muscle weakness.Resident 3 was admitted to the facility in early 2022 with diagnosis which included dementia, failure to thrive, and muscle weakness.Resident 4 was admitted to the facility in early 2021 with diagnosis which included major depressive disorder, dementia, and need for assistance with personal care.Resident 5 was admitted to the facility in late 2020 with diagnosis which included difficulty communicating, muscle weakness, and lack of muscle coordination.During an observation and interview on 1/28/26 at 10:52 a.m. with Resident 1 in Resident 1's room, Resident 1 stated there were bugs in her room, They are everywhere. Resident 1 pointed to a small fly on the privacy curtain. Observed a small fly on her privacy curtain, several small flies hovering in the air, and several flies on the wall.During an observation on 1/27/26 at 11:11 a.m. of Resident 3's room, Resident 3's bed was unmade, there was a small black fly on his pillowcase, there were multiple flies on the privacy curtain and wall. On Resident 3's bedside table was a sandwich in plastic wrap, there were multiple small flies on and inside the wrapper, there were small flies on the speaker end of his phone, and on his drinking cup.During an observation on 1/27/26 at 11:13 a.m. of Resident 4's room, Resident 4 was lying in his bed, a thick yellow dried substance was on the sheets, the bed frame and pooled on the floor. There were numerous small black flies on his mattress, the bed frame, the wall and the privacy curtain. There were several small flies on Resident 4's gown and one on his pillowcase. Multiple flies were slowly flying around his head.During an observation on 1/27/26 at 11:15 a.m. of Resident 5's room, Resident 5 was lying in bed, he was unable to answer my questions. Observed multiple small black flies on the privacy curtain and flying around.During a concurrent observation and interview on 1/27/26 at 11:16 a.m. with Certified Nursing Assistant 1 (CNA) in the shared room of Resident 3, Resident 4 and Resident 5, CNA 1 confirmed the flies and stated, It's not supposed to be like that.During a concurrent observation and interview on 1/27/26 at 11:17 a.m. with the Housekeeping Manager (HM) in the shared room of Resident 3, Resident 4 and Resident 5, the HM confirmed the presence of flies on multiple surfaces including the sandwich and phone of Resident 3, on the mattress and pillow of Resident 4, and flying around.During an observation on 1/27/26 at 11:22 p.m. of Resident 2's room, several flies were flying in the room. One small black fly was observed on the lid of a cup.During a concurrent observation and Page 1 of 2 056238 056238 01/27/2026 Solano Post Acute 2200 Tuolumne Street Vallejo, CA 94589

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interview on 1/27/27 at 11:25 a.m. with Resident 4 in his room, Resident 4 was waving away flies from in front of his face and stated the flies had been here awhile. Resident 4 stated he was unable to get out of bed on his own and stated the flies bothered him.During a concurrent observation and interview on 1/27/26 at 11:37 a.m. with the Administrator (ADM) of the shared room of Resident 3, Resident 4 and Resident 5, the ADM confirmed presence of multiple flies and stated, It should not be like this.During an interview on 1/27/26 at 12:53 p.m. with the Infection Preventionist (IP), the IP was shown a picture of the flies, and stated her expectation was for residents to have a safe and clean environment to prevent infections. The IP further stated the flies could cause GI (gastro-intestinal) and respiratory issues.During an interview on 1/27/26 at 3:04 p.m. with the Assistant Director of Nursing (ADON), the ADON was shown pictures of the flies on Resident 4's bed and clothing and the dried tan liquid on his sheets and bedframe, the ADON stated she would not expect to see that in the facility, That is not good for someone with depression or for anyone. During a review of the facility policy and procedures (P&P) titled, Infection Prevention and Control Program, dated 9/23, the P&P indicated, An infection prevention and control program (ICPC) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.During a review of the facility P&P titled, Pest Control, dated 5/08, the P&P indicated, Our facility shall maintain an effective pest control program.This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.Maintenance services assist, when appropriate and necessary, in providing pest control services.During a review of the facility P&P titled, Homelike Environment, dated 2/21, the P&P indicated, Residents are provided with a safe, clean, comfortable and home like environment and encouraged to use their personal belongings to the extent possible.clean, sanitary and orderly environment.clean bed and bath linens.During a review of the facility P&P titled, Resident Rights, dated 10/25, the P&P indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence. 056238 Page 2 of 2