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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005946
Report Date: 09/25/2026
Date Signed: 09/25/2026 01:58:07 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/06/2026 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20260706155046
FACILITY NAME:SERRA SOLFACILITY NUMBER:
306005946
ADMINISTRATOR:CHRISTINE GREENWAYFACILITY TYPE:
740
ADDRESS:31451 AVENIDA LOS CERRITOSTELEPHONE:
(949) 485-2022
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:70CENSUS: 42DATE:
09/25/2026
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Christine GreenwayTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Staff do not provide activities
Staff do not follow reporting requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as activity schedule. Regarding the allegations that staff do not follow reporting requirements and staff do not provide activities, the investigation revealed the following: Facility provided a death report for Resident 1 (R1) dated 06/19/2026 showing cause of death as natural. Resident was admitted to hospice care. Facility submitted an incident report for R2 eloping out of the facility on 05/02/2026. The department addressed the incident on 05/13/2026. LPA reviewed an extensive activity calendar including games, exercise, and coastal drives. LPA observed residents participating in activities. Per staff, all residents are allowed to participate in the activities and nobody is denied. Based on record review and observation, facility is reporting incidents and providing activities. CONTINUED ON LIC 9099C DATED 09/25/2026.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/06/2026 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20260706155046

FACILITY NAME:SERRA SOLFACILITY NUMBER:
306005946
ADMINISTRATOR:CHRISTINE GREENWAYFACILITY TYPE:
740
ADDRESS:31451 AVENIDA LOS CERRITOSTELEPHONE:
(949) 485-2022
CITY:SAN JUAN CAPISTRANOSTATE:CAZIP CODE:
92675
CAPACITY:70CENSUS: 42DATE:
09/25/2026
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Christine GreenwayTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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2
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9
Licensee does not ensure staff have required training
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as staff training records. Regarding the allegation that Licensee does not ensure staff have required training, the investigation revealed the following: LPA reviewed training records for four staff. Two out of four staff do not have required annual topics in the transcript. Based on records reviewed, the preponderance of evidence has been met, therefore the allegation is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.
An exit interview was conducted with Administrator and a copy of this report along with the Appeal Rights were provided at the time of this visit.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 22-AS-20260706155046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SERRA SOL
FACILITY NUMBER: 306005946
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/09/2026
Section Cited
HSC
1569.625(b)(2)
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(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually.. four hours of which shall be specific to postural supports, restricted health conditions, and hospice care....
This requirement is not met as evidenced by:
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Licensee to conduct training and forward proof to LPA by POC due date.
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Based on record review, Licensee failed to ensure S1 and S2 received training on postural supports which poses a potential health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/06/2026 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20260706155046

FACILITY NAME:SERRA SOLFACILITY NUMBER:
306005946
ADMINISTRATOR:CHRISTINE GREENWAYFACILITY TYPE:
740
ADDRESS:31451 AVENIDA LOS CERRITOSTELEPHONE:
(949) 485-2022
CITY:SAN JUAN CAPISTRANOSTATE:CAZIP CODE:
92675
CAPACITY:70CENSUS: 42DATE:
09/25/2026
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Christine GreenwayTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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2
3
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8
9
Staff do not ensure residents' showering needs are being met
Staff do not ensure residents' toileting needs are being met
Staff do not adequately supervise residents
Staff do not provide adequate supervision resulting in residents' eloping
Staff mismanage residents' medication
Staff do not ensure medication is kept in its original container
INVESTIGATION FINDINGS:
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2
3
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility and interviewed staff. Regarding the allegations that staff do not ensure residents' showering needs are being met, staff do not ensure residents' toileting needs are being met, staff do not adequately supervise residents, staff do not provide adequate supervision resulting in residents' eloping, staff mismanage residents' medication and staff do not ensure medication is kept in its original container, the investigation revealed the following: Facility staffing runs as follows per staff schedule: Four to five caregivers on 1st and 2nd shift with a med tech and two caregivers and a med tech on the overnight shift. Five out of five staff state that staffing can run low at times but resident needs are being met. All caregivers interviewed stated that sometimes showers are pushed off to the next shift if there is a call out but the showers are eventually done. Five out of five care givers state checking residents every 2-3 hours for incontinence care CONTINUED ON LIC 9099C DATED 09/25/2026
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20260706155046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SERRA SOL
FACILITY NUMBER: 306005946
VISIT DATE: 09/25/2026
NARRATIVE
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but that residents are generally all together in the common area so they are easily observed and checked. One out of five staff states sometimes residents are wet when the staff come on shift. Facility had an elopement incident with R2 on May 02, 2026 which was previously addressed by the department on May 13, 2026. The incident occurred when the resident was mistakenly identified as a visitor by staff that were present at the time. Facility denies knowledge of other elopement incidents but states there are residents who are exit seeking that staff monitor. During the investigation, LPA reviewed select resident medications and toured the medication room. LPA observed no evidence of any pre-pouring of medications and staff deny knowledge of pre-poured medications. LPA observed medications on hand match physician orders and medications appear to be administered per physician order. Five out of five staff deny knowledge of staff being rough with residents. LPA reviewed two SOC 341 reports indicating Staff 3 had been rough with residents. Administrator indicated the internal investigation showed the allegation came from personal disagreements between staff.

Based on records reviewed and interviews conducted, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview was conducted and copy of the report was provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 22-AS-20260706155046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SERRA SOL
FACILITY NUMBER: 306005946
VISIT DATE: 09/25/2026
NARRATIVE
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Therefore, the allegations are deemed UNFOUNDED, meaning that the allegations are false, could not have happened and/or is without a reasonable basis.
Exit interview conducted and copy of report provided
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6