306005946-5-14-2026-22-AS-KSGH-DUPVVG-20260603164620

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005946
Report Date: 05/14/2026
Date Signed: 05/14/2026 11:55:16 AM

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
03/12/2026 and conducted by Evaluator Eboni Bentley

COMPLAINT CONTROL NUMBER: 22-AS-20260312123306

FACILITY NAME:	SERRA SOL		FACILITY NUMBER:	306005946
ADMINISTRATOR:	LINDSAY SCHROEDER		FACILITY TYPE:	740
ADDRESS:	31451 AVENIDA LOS CERRITOS		TELEPHONE:	(949) 485-2022
CITY:	SAN JUAN CAPISTRANO	STATE: CA	ZIP CODE:	92675
CAPACITY:	70	CENSUS: 41	DATE:	05/14/2026
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Christine Greenway - Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not properly address resident's multiple falls at facility.

INVESTIGATION FINDINGS:

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On May 14, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced for the purpose of conducting a subsequent complaint investigation into the above allegation. LPA was greeted, introduced self, and was granted entry after stating the purpose of the visit to staff. Administrator (Admin) Christine Greenway was contacted via telephone and arrived shortly to assist with the visit.

LPA reviewed copies of facility documents including: Resident Roster, Staff Roster, Resident #1's (R1's) Emergency Info & Contact Sheets, Physician's Reports, Admissions Agreement, Service Plan, Incident Reports, Physician Fax Communications, and hospital discharge records. Interviews were successfully conducted with staff and witnesses.

Continue to LIC9099-C.....

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026

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 4

Control Number 22-AS-20260312123306

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
	VISIT DATE: 05/14/2026

NARRATIVE

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The investigation revealed the following:

Regarding the allegation, Staff did not properly address resident's multiple falls at facility, it is alleged that staff did not prevent Resident #1 (R1) from sustaining multiple falls while in care within a two year period. LPA inspected the facility, conducted health and safety checks on residents in care, and did not observe any health and safety issues during the visits. R1 moved into the memory care facility on October 4, 2021, and based on the Physician’s Report dated October 1, 2021, R1 was ambulatory, able to communicate needs, and had a diagnosis of Alzheimer’s Disease Dementia with delusions and behavior issues. A Physician’s Reports dated March 20, 2024 indicated R1 was non-ambulatory, able to communicate needs, and had the same diagnosis. LPA reviewed R1’s Physician Fax Communications sent by the facility and hospital discharge records which state that: on June 1, 2023, R1 sustained an unwitnessed fall and taken to the hospital for evaluation by family; on October 27, 2023, R1 was assessed by Home Health, was able to ambulate with normal gait pattern and with noted instability; on December 4, 2023 R1 sustained a witnessed fall resulting in R1 hitting their head and was transferred to the hospital for evaluation; on February 2, 2024, R1 was transferred to the hospital due to a fall; on February 24, 2024, R1 sustained an unwitnessed fall resulting in rug burn, an abrasion on her right elbow and first aid was applied; on February 25, 2024, R1 had an unwitnessed fall, ambulated and expressed pain on right elbow; on March 3, 2024, R1 sustained an unwitnessed fall in a common room, was able to ambulate and had no signs of pain or injuries; on April 7, 2024, R1 sustained an unwitnessed fall in their bathroom and staff observed bruising from a previous fall. Based on records reviewed, R1 nine sustained falls between June 1, 2023 and April 7, 2024 and voluntarily moved out on May 16, 2024.

The facility held multiple care plan meetings between October 4, 2021 and February 1, 2024, however, R1 was not assessed to be a high risk for falls and additional measures to address R1’s fall risk were not included. Four out of four staff interviewed stated they are unaware of the fall prevention measures put in place for R1 and the facility was unable to provide any fall prevention plan documentation during the course of the investigation. LPA reviewed the facility’s staff schedule and did not note any staffing issues that may have contributed to R1’s falls. LPA interviewed R1’s responsible party who had concerns about the care R1 was receiving at the facility but did not provide any supportive evidence.

Continue to LIC9099-C.....

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 22-AS-20260312123306

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
	VISIT DATE: 05/14/2026

NARRATIVE

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Even though R1 had no visible injuries during some of the falls, it was imperative that facility document and implement a fall prevention plan specific to R1’s Dementia diagnosis. Therefore, based on the Department’s interviews that were conducted and the records reviewed, the preponderance of evidence standard has been met, and the following allegation: Staff did not properly address resident's multiple falls at facility is deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. A deficiency is being cited on the attached LIC9099D.

An exit interview was conducted with Administrator Christine Greenway, a copy of this report, LIC809-D, LIC811, and appeal rights were provided at the end of the visit.

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20260312123306

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: 05/14/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/22/2026 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Executive Director, Christine Greenway, stated that all care staff will be trained to meet all residents’ fall needs, and will submit an Acknowledgement of Understanding of the said deficiency. The above statement and training records will be submitted to LPA via email by POC due date.
	8 9 10 11 12 13 14	Based on interviews and record review, licensee did not find a solution necessary to prevent R1’s from sustaining multiple fall and a fall risk plan was not implemented, which posed an potential Health, Safety, and/or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026

LIC9099 (FAS) - (06/04)

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