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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005946
Report Date: 03/11/2024
Date Signed: 03/11/2024 01:40:10 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/01/2024 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240301164328
FACILITY NAME:SERRA SOLFACILITY NUMBER:
306005946
ADMINISTRATOR:LOPEZ, JANELLEFACILITY TYPE:
740
ADDRESS:31451 AVENIDA LOS CERRITOSTELEPHONE:
(916) 836-8022
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:70CENSUS: 48DATE:
03/11/2024
UNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Lindsay SchroederTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility did not provide resident's complete medical records to resident's authorized representative.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Executive Director Lindsay Schroeder and explained the reason for the visit. The investigation revealed the following. It was alleged that the facility did not provide all of the records for Resident 1 to the authorized representative after they were requested. The request for, "the complete chart" was received by the facility on February 21, 2024. On February 28, 2024 the facility emailed to the authorized representative of Resident 1, 147 pages, including the Admission Agreement, Physician's report and resident information. The Administrator verified that the information sent to the authorized representative did not include the Resident's medication administration records and resident notes. Based on the evidence gathered the preponderance of evidence standard has been met, therefore the allegation is substantiated. Citation is being cited per Title 22, division 6 of the California Code of Regulations. An exit interview was conducted, a copy of the this report along with citation and appeal rights was provided to the facility representative.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20240301164328
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SERRA SOL
FACILITY NUMBER: 306005946
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2024
Section Cited
HSC
1569.269(a)(21)
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(21)To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. This requirement
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Licensee agrees to have the Administrator provide a statement of understanding for the regulation HSC 1569.269 and to provide Resident 1's authorized representative their medication administration records and resident notes. Administrator to provide POC to LPA by POC due date.
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was not met as evidenced by, the facility did not provide Resident 1's medication administration records and resident notes. This poses a potential health and safety risk to residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
LIC9099 (FAS) - (06/04)
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