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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005946
Report Date: 08/26/2022
Date Signed: 08/26/2022 04:24:57 PM

Unsubstantiated


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
08/18/2022 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220818105808
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: 34DATE:
08/26/2022
UNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Susie Peterson, Khatera BahadoryTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff do not assist residents with showering.
Staff do not assist residents with grooming.
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 allegations listed above. LPA was greeted and granted entry by staff. LPA was screened for Covid-19 prior to entry into the facility. LPA met with Executive Director (ED) Susie Peterson Director of Nursing Khatera Bahadory. LPA explained the reason for the visit. LPA interviewed Executive Director and Director of Nursing and staff. LPA requested resident records, such as Admission Agreements, Physician Reports and medication records and needs and service plans. The investigation into the allegations revealed the following. LPA toured the facility and met with residents. LPA did not observe any evidence that residents were not groomed or showered. LPA observed none of the residents were wearing dirty or soiled clothing. Staff reported all residents are showered at least twice a week. Staff reported that no hygiene items like soap or hair brushes are shared among residents. LPA inspected 2 resident rooms and observed hygiene supplies including soap and toothpaste. No evidence was observed that corroborates the allegations.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
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-20220818105808
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: 08/26/2022
NARRATIVE
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 Based on the evidence the allegations, staff do not assist residents with showering and staff do not assist residents with grooming are 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.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2