Somerset Post Acute Care
151 Claydelle Ave, El Cajon, CA 92020 · San Diego County · 65 certified beds · avg 44 residents/day · certified since Jul 22, 2011
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
3/5
Health inspection rating (on-site)
1
Serious findings on record
$26,728
Fines, last 3 years
4.22
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Mar 21, 2024 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 19, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (43)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 9, 2026 | E · Potential for harm, repeated | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Jan 7, 2026 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Jul 16, 2025 | E · Potential for harm, repeated | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Mar 13, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 13, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 5, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 13, 2024 | D · Potential for harm, one-off | The facility did not let a resident return after a hospital stay or approved leave that lasted longer than the facility's bed-hold policy allowed. Residents generally have the right to come back to the next available bed. · from a complaint |
| Dec 13, 2024 | D · Potential for harm, one-off | The facility did not have an agreement with at least one Medicare- or Medicaid-certified hospital to ensure residents can be transferred quickly when they need hospital care. · from a complaint |
| Mar 21, 2024 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Mar 21, 2024 | E · Potential for harm, repeated | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Mar 21, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Mar 21, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Mar 21, 2024 | E · Potential for harm, repeated | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Mar 21, 2024 | D · Potential for harm, one-off | The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. |
| Mar 21, 2024 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Mar 21, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Mar 21, 2024 | D · Potential for harm, one-off | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Mar 21, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Mar 21, 2024 | D · Potential for harm, one-off | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Mar 21, 2024 | B · Minimal risk, repeated | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Dec 8, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jun 23, 2022 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jun 23, 2022 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jun 23, 2022 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| Jun 23, 2022 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jun 23, 2022 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jun 23, 2022 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jun 23, 2022 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jun 23, 2022 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Jun 23, 2022 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Jun 23, 2022 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (12 → 14).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 10 | 0 | E |
| 2023 | 1 | 0 | D |
| 2024 | 14 | 1 | G ▲ |
| 2025 | 16 | 0 | E |
| 2026 | 2 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $26,728.
| Date | Type | Amount / length |
|---|---|---|
| Mar 21, 2024 | Fine | $26,728 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | California avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.22 | 4.31 | 3.95 | top 43% in California; top 31% in the U.S. |
| Registered Nurse hours | 0.64 | 0.61 | 0.69 | top 29% in California; top 43% in the U.S. |
| Weekend total nurse staffing | 3.65 | 3.90 | 3.50 | bottom 43% in California; top 35% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.54 | 0.51 | 0.48 | top 28% in California; top 29% in the U.S. |
| Total nursing staff turnover (%) | 61.9 | 36.7 | 45.8 | bottom 2% in California; bottom 14% in the U.S. |
| RN turnover (%) | 80.0 | 38.1 | 42.9 | bottom 4% in California; bottom 6% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.68, RN 0.71, weekend 4.05. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 4/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Avocado Health Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2014 |
| Burnam, Soon | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/10/2014 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 09/10/2014 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2014 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Matthews, Glenn | Individual | Managing Control - Governing Body | NOT APPLICABLE | 12/01/2014 |
| Matthews, Glenn | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2014 |
| Matthews, Glenn | Individual | ADP of the SNF | NOT APPLICABLE | 07/10/2025 |
| Michlin, Bernard | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/01/2024 |
| Michlin, Bernard | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2024 |
| Michlin, Bernard | Individual | ADP of the SNF | NOT APPLICABLE | 07/10/2025 |
| Port, Barry | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 07/10/2025 |
| Standard Bearer Healthcare Op, LP | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2014 |
| The Ensign Group INC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2014 |
| Twomagnets LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/01/2014 |
| Willits, Adam | Individual | Corporate Director | NOT APPLICABLE | 09/01/2017 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Magnolia Post Acute Care | 0.4 mi | El Cajon, CA | ★★★☆☆ | 2/5 | abuse |
| Stillwater Post-Acute | 0.4 mi | El Cajon, CA | ★★☆☆☆ | 2/5 | |
| Parkside Health and Wellness Center | 0.6 mi | El Cajon, CA | ★★★★★ | 5/5 | |
| Villa Las Palmas Healthcare Center | 0.7 mi | El Cajon, CA | ★★★☆☆ | 3/5 | |
| Victoria Post Acute Care | 0.7 mi | El Cajon, CA | ★★★★★ | 4/5 | |
| San Diego Post-Acute Center | 1.0 mi | El Cajon, CA | ★☆☆☆☆ | 1/5 | abuse |
| Cottonwood Canyon Healthcare Center | 1.8 mi | El Cajon, CA | ★★★☆☆ | 2/5 | |
| Granite Hills Healthcare & Wellness Centre, LLC | 1.8 mi | El Cajon, CA | ★★☆☆☆ | 2/5 | |
| Bradley Court | 1.8 mi | El Cajon, CA | ★★★★★ | 5/5 | |
| Country Hills Post Acute | 2.5 mi | El Cajon, CA | ★☆☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 555871.