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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005946
Report Date: 08/13/2025
Date Signed: 08/13/2025 05:11:28 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
08/23/2021 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210823125938
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: 61DATE:
08/13/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lindsay SchroederTIME COMPLETED:
05:25 PM
ALLEGATION(S):
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Lack of supervision resulting in resident engaging in a physical altercation with another resident.
Staff yelled at resident.
Staff disturbing residents sleep.


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 Executive Director (ED) Lindsay Schroeder and explained the reason for the visit.

The investigation into the allegation, Staff disturbing residents sleep, revealed the following. Resident 1 (R1) moved into the facility on June 10, 2021, and moved out of the facility on August 21, 2021. It was reported that Staff woke up R1 at 6:08 am for a temperature check and at 6:45 am for a shower. No dates were provided as to when these incidents occurred. Witness 1 (W1) reported that R1 told them about the shower at 6:15 am but they were not present at the facility when it took place. A review of records for R1 shows the facility did not perform any temperature checks on R1 that were documented. Staff interviewed reported they don’t do a temperature check unless instructed to by a doctor. Facility progress notes show that R1 was given a shower at 6:15 am on July 10, 2021. R1 has a history of getting up early, on August 7 6:20 am, July 27 6:45 am, June 26 6:30 am, June 24
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
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 8
Control Number 22-AS-20210823125938
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: 08/13/2025
NARRATIVE
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6:30 am, June 23 6:30 am, June 19 7:00 am, June 18 5:30 am, June 17 5:30 am and June 15 6:30 am. 5 out of 5 staff interviewed reported that R1 gets up early and will start to get ready for the day by showering or shaving on their own. Staff reported that when they see R1 is awake they will assist. The Wellness Director reported that no one has reported that staff are waking up residents early in the morning to shower them or take their temperature. R1 moved out of the facility prior to the visit. None of the evidence gathered supports the allegation therefore 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 yelled at resident, revealed the following. It was reported on June 23, 2021, staff yelled at R1. Witness (W1) reported that R1 called them and then forgot to hang up the phone and they heard a staff member yell at R1, “get out of bed, shut the hell up”. No other evidence was provided to support the allegation. Staff 1 (S1), Staff 2 (S2) and Staff 3 (S3) who were present at the facility on the night of June 23 denied the allegation. S1 and S2 reported they assessed R1 that night and reported no one was yelling at anyone that night. S3 reported they did not hear anyone yelling that night. 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 Lack of supervision resulting in resident engaging in a physical altercation with another resident, revealed the following. It was reported that a female resident (name unknown) agitated R1 and then another resident, Resident 2 (R2) provoked R1. R1 then pushed R2 who fell on the ground. W1 reported that this was because there was a lack of supervision. A review of records shows that on July 8, 2021, 2 staff were present assisting the residents (8). R1 had their own care companion. On July 8, R1 told R2, “No you can’t come in here”. Then R1 pushed R2. R1’s care companion attempted to break R2’s fall but R2 still fell to the ground. Staff 4 (S4) and Staff 5 (S5) who were present redirected R1 and assisted R2. 911 was called and R2 was transported to the hospital but returned the same day with no new orders and no injuries. R1 has been diagnosed with Dementia and on their physician’s, report is noted to have aggressive and wandering behavior. R1 does have a private care companion and staff immediately acted to redirect R1 and to assist R2. S4 and S5 reported they are always checking on residents to ensure their safety and redirecting residents when necessary.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 22-AS-20210823125938
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: 08/13/2025
NARRATIVE
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The facility has done what it can to minimize the risk to all residents concerning aggressive behavior and has not displayed a lack of supervision regarding this 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.

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: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 8
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
08/23/2021 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210823125938

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: 61DATE:
08/13/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lindsay SchroederTIME COMPLETED:
05:25 PM
ALLEGATION(S):
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CCL poster not visible to residents.
Staff did not notify authorized representative of residents medical/medication changes.
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 Executive Director (ED) Lindsay Schroeder and explained the reason for the visit.

The investigation into the allegation, CCL poster not visible to residents, revealed the following. It was reported that residents cannot see the CCL poster, also known as the See Something, Say Something Poster (PUB 475) that is posted in the main entrance of the facility (lobby). The facility is a memory care facility with an approved secured perimeter. The lobby is not accessible to residents but the door from the lobby to the rest of the facility has a large glass window. The walls of the lobby have large windows all along the side which is next to the main facility hallway. The regulation covering the PUB 475 poster, California Code of Regulations (CCR) Title 22, Division 6, 87468(c)(2)(A) states, “The poster that is posted shall be 20" x 26" in size and be posted in the main entryway of the facility.”. The facility is in compliance regarding the posting of the PUB 475 poster.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
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 8
Control Number 22-AS-20210823125938
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: 08/13/2025
NARRATIVE
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The entire lobby including the See Something, Say Something Poster (PUB 475) is visible from the main facility hallway. 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.

The investigation into the allegation, Staff did not notify authorized representative of residents medical/medication changes, revealed the following. It was reported that the authorized representative/Responsible Party (RP) was not notified of any medical or medication changes. A review of R1’s records show that R1 did not undergo a change of condition while they were at the facility. R1 was prescribed 4 routine medications, Losartan, Omega 3, Vitamin D3 and Quetiapine. Vitamin D3 was added at R1’s RP’s request. Seroquel was changed to a PRN at the request of the RP. No other changes were noted in R1’s records. No specific details were provided as to what the RP was not notified of except for medical/medication changes. The medication changes were prompted by the RP and there were no medical changes reported. The facility did not have any medical or medication changes to report to the RP. Based on the evidence gathered the allegation deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

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: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 8
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
08/23/2021 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210823125938

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: 61DATE:
08/13/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lindsay SchroederTIME COMPLETED:
05:25 PM
ALLEGATION(S):
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Lack of supervision resulted in resident AWOL.
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 Executive Director (ED) Lindsay Schroeder and explained the reason for the visit.

The investigation into the allegation, Lack of supervision resulted in resident AWOL revealed the following. It was reported that R1 left the facility unattended on June 23, 2021, because of a lack of supervision. LPA interviewed 2 staff members and the Executive Director (ED). Staff 1 (S1) and Staff 2 (S2) were present at the time of the elopement. Witness 1 (W1) reported that they received a call from R1 who told them they did not know where they were. W1 called the facility to verify R1 was at the facility. Staff reported that R1 was not at the facility. W1 reported that R1 left the facility at around 9:00 pm. R1 left the facility through the front door and walked to a local gas station where the attendant called 911.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 22-AS-20210823125938
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: 08/13/2025
NARRATIVE
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Local Law Enforcement arrived and transported R1 back to the facility around 9:30 pm and staff assessed R1 and no injuries were noted. S1 and S2 verified this report. The ED reported that the staff have been trained on proper elopement protocol and proper supervision to verify the location of all residents to prevent elopement. According to R1's physician report they are not allowed to leave the facility unassisted. Based on the evidence gathered the preponderance of evidence standard has been met therefore the allegation is substantiated. Citation is being cited per Title 22, division 6 of the California Code of Regulations.

An exit interview was conducted, and a copy of the report along with the citation and appeal rights was provided to the facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 22-AS-20210823125938
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: 08/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/14/2025
Section Cited
CCR
87705(e)(5)
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Care Of Persons With Dementia 87705(e)(5) Facility staff shall ensure the continued safety of residents if they wander away from the facility...

This requirement is not met as evidence by:
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Licensee agrees to train all staff on elopement prevention training and to provide proof of training to LPA by the POC due date.
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Resident 1 left the facility unattended on June 23, 2021 for approximately 30 minutes which poses an immediate health, safety and personal rights 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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8