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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005946
Report Date: 08/10/2022
Date Signed: 08/10/2022 11:27:46 AM


Document Has Been Signed on 08/10/2022 11:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



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: 36DATE:
08/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Susie Peterson,Khatera Bahadory TIME COMPLETED:
11:43 AM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to follow up on an incident report received on 8/9/22. LPA met with Executive Director (ED) Susie Peterson and Director of Nursing Khatera Bahadory. LPA explained the reason for the visit. The incident reported concerned Resident 1 (R1) becoming aggressive toward staff and Resident 2 (R2). Around 6:30 pm on 8/8/22 R1 became agitated. Staff noticed this and walked alongside R1. R1 attempted to push R2 who was standing in front of R1. Staff intervened and separated the residents. R1 was still agitated and did not respond to staff attempting to redirect and de-escalate the situation. Staff called 911. The family was notified and agreed to send R1 to the hospital. R1 returned the next day. The facility contacted R1's physician who adjusted R1's medication. No injuries were noted on R1, R2 or staff. The facility ensured all residents were unharmed and reported the incident to the required parties. LPA observed R1 at the facility. R1 had no visible injuries and was sitting in the dining room getting ready to have lunch. R2 was out of the facility on an activity with other residents and facility staff. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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