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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005946
Report Date: 04/15/2026
Date Signed: 04/15/2026 05:28:14 PM

Unsubstantiated


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
01/06/2025 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250106132300
FACILITY NAME:SERRA SOLFACILITY NUMBER:
306005946
ADMINISTRATOR:LINDSAY SCHROEDERFACILITY TYPE:
740
ADDRESS:31451 AVENIDA LOS CERRITOSTELEPHONE:
(949) 485-2022
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:70CENSUS: 42DATE:
04/15/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Christine GreenwayTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Licensee does not ensure facility has sufficient staffing to meet the needs of residents in care
Staff allow residents to be left in soiled clothing for extended periods of time
Staff do not ensure residents are provided assistance with meal service
Staff do not ensure all residents receive bathing services
Staff do not ensure residents are provided with social activities for engagement and interaction.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Administrator Christine Greenway and explained the reason for the visit.

The investigation into the allegation, Licensee does not ensure facility has sufficient staffing to meet the needs of residents in care, revealed the following. It was reported that the facility does not have enough staff to ensure residents are being escorted to meals, being showered, dressed and groomed properly and being assisting with all of their activities of daily living. The Administrator, Lindsay Schroeder, reported that the facility is fully staffed and they haven't had any staffing issues or complaints. LPA reviewed the staff schedule for November and December 2024. The schedule shows that for the from 6:00 am until 10:00 pm there are 4 caregivers and 1 medication technician (med-tech) and for the overnight shift (NOC) there are 2 caregivers and 1 med-tech are scheduled. 7 out of 7 staff interviewed (med-techs and caregivers) reported no issues with staffing.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026
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 5
Control Number 22-AS-20250106132300
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: 04/15/2026
NARRATIVE
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In addition to the caregivers, there is the Administrator, Wellness Director, head chef, 2 kitchen staff and one housekeeper and the maintenance director. A review of incident reports shows, the facility submitted 3 incident reports for November 2024 and 5 for December 2024. None of the reports required any type of follow up. The number of reports received for the facility is no cause for concern. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, staff allow residents to be left in soiled clothing for extended periods of time, revealed the following. R1 moved into the facility on November 1, 2024 and moved out of the facility on December 18, 2024. It was reported that on November 30, 2024, Witness 1 (W1) went to visit Resident 1 (R1) and found R1 in soiled clothing. W1 reported that R1 was shaking because they were not fed, did not receive their medicaiton and was in soiled clothing after an incontinence issue. No other details were provided. A review of R1's progress notes shows no incidents or issues reported for November 30, 2024. There is no mention of incontinence issues for R1 in any of the progress notes. 5 out of 5 caregivers interviewed reported that none of the residents including R1 have been left in soiled clothing and are assisted immediately. 5 out of 5 caregivers interviewed reported that R1 does wear incontinence briefs but is very good at going to the bathroom and is easily identified if they need to be changed. 7 out of 7 staff interviewed (caregivers and med-techs) reported they are unaware of any incidents on November 30, 2024, involving R1 shaking or being in soiled clothing. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, staff do not ensure residents are provided assistance with meal service, revealed the following. It was reported that R1's weight dropped because they were not being served breakfast or lunch and they were not escorted to the dining area. It was also reported that on November 30, 2024, when W1 visited R1, R1 was shaking because they not fed breakfast or lunch. R1 moved out of the facility on December 18, 2024 and their location is unknown so they were never interviewed. W1 reported that R1 did not eat breakfast or lunch on November 30, 2024, but they were not at the facility during breakfast or lunch hours. 5 out of 5 caregivers reported that R1 never missed a meal and was always escorted to each meal. A review of R1's progress notes does not show any entry for November 30, 2024 or any issues regarding meals. The Wellness Director and the Administrator reported that they never received any reports or complaints regarding R1 or any resident concerning meal service or eating issues.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
01/06/2025 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250106132300

FACILITY NAME:SERRA SOLFACILITY NUMBER:
306005946
ADMINISTRATOR:LINDSAY SCHROEDERFACILITY TYPE:
740
ADDRESS:31451 AVENIDA LOS CERRITOSTELEPHONE:
(949) 485-2022
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:70CENSUS: 42DATE:
04/15/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Christine GreenwayTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
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9
Staff do not ensure medications are dispensed as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Administrator Christine Greenway and explained the reason for the visit.

The investigation into the allegation, staff do not ensure medications are dispensed as prescribed, revealed the following. It was reported that would mix up Resident 1's (R1) medication or not administer it. Witness 1 reported that R1 did not receive all of their medications, but could not provide any details. The Wellness Director reported that R1 had refused medications on 5 different occasions, which was documented but overall they receive all of their medication. 2 out of 2 medication-technicians (med-techs) reported that R1 receives their medicaiton as prescribed with no issues except for the times they refused medication. A review of R1's medication administration record (MAR) R1 received all of their medications except when they refused, twice on November 9, once on November 25, once on November 30 and once on December 14, 2024.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20250106132300
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: 04/15/2026
NARRATIVE
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The Wellness Director and the Administrator reported that they have not received any complaints concerning R1 and their medications. Based on the evidence gathered the allegation is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with the Administrator and a copy of the report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20250106132300
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: 04/15/2026
NARRATIVE
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None of the evidence gathered supports the allegation. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, staff do not ensure all residents receive bathing services, revealed the following. It was reported that R1 was not receiving bathing services daily and R1 would only receive a bath/shower when R1's family provided it during their visits. W1 reported that staff had told them none of the staff every gave R1 a bath or shower. W1 did not provide any details or names of the staff involved. The Wellness Director reported that most residents are showered 2 or 3 times a week and as needed if one is required. The Wellness Director reported they are unaware of any resident not receiving regular showers. The Administrator and Wellness Director reported that no one has complained to them about not receiving showers. A review of records shows that on R1's care plan completed at the time of move in, R1 is to receive 2 showers a week on Mondays and Fridays at 9:00 am, and as needed. 5 out of 5 caregivers interviewed reported that R1 received showers on Mondays and Fridays and on most days when family visited. 5 out of 5 caregivers reported that R1's family would regularly shower R1 and dress and groom them. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, staff do not ensure residents are provided with social activities for engagement and interaction. It was reported that staff did not interact with R1 and did not provide R1 with social activities. W1 reported that staff would take R1 to the activity room and leave them there without interacting with R1 or attempting to have R1 participate in a group activity. The Activities Director reported that each day staff encouraged R1 to participate in group activities (stretching, balloon toss), music activities (singing and dancing) and craft activities (painting), and R1 showed no interest in any of them. 3 out of 5 caregivers interviewed reported that R1 preferred to be in the TV room and watch TV. The Activities Director reported that R1 was always encouraged to participate and would sit for a minutes and then walk to the TV room. The Administrator and the Wellness Director reported that they never received any complaints regarding R1 and activities. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5