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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005946
Report Date: 06/21/2024
Date Signed: 06/21/2024 02:14:51 PM


Document Has Been Signed on 06/21/2024 02:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



FACILITY NAME:SERRA SOLFACILITY NUMBER:
306005946
ADMINISTRATOR:LINDSAY SCHROEDERFACILITY TYPE:
740
ADDRESS:31451 AVENIDA LOS CERRITOSTELEPHONE:
(916) 836-8022
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:70CENSUS: 40DATE:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Lindsay SchroederTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted by staff and granted entry. LPA met with Executive Director (ED) Lindsay Schroeder and explained the reason for the visit. Lindsay Schroeder's Administrator's certificate expires on January 21, 2025. Facility is a two story building with 2 courtyards (one on each floor) and surrounding parking lot. No bodies of water observed. Facility is approved for delayed egress exits and a secured perimeter. LPA and the Executive Director toured the facility. LPA observed the See Something, Say Something poster (PUB 475) posted in the entry way of the facility. LPA observed the kitchen is clean and organized. There is a two day supply of perishable food and a seven day supply of non-perishable food on-hand in the kitchen. LPA observed that the refrigerators and the freezers had temperature logs posted on them. The refrigerators and freezers were at the required temperatures. LPA and ED toured 5 resident rooms on the first and second floors. All resident rooms had the required furnishings and bed linens. All resident bathrooms were clean and operational. The hot water in the 5 resident rooms inspected measured 111.2 degrees Fahrenheit to 114.4 degrees Fahrenheit. LPA observed residents watching a musical performance in the dining room. There is an activity room with games and puzzles and a TV room for residents. There is an outdoor courtyard on each floor with shaded seating for residents to sit outside. There are fire extinguishers on each floor and all fire extinguishers are fully charged. LPA observed an emergency evacuation chair at the top of the stairwell. The last emergency disaster drill was conducted on April 25, 2024. The delayed egress exits tested operational. The fire alarm/fire detection system was inspected and tested operational on February 13, 2024. LPA observed medications are kept secured in a medication cart that is locked in the medication room. LPA observed that the First Aid Kit had all the required elements. LPA interviewed staff and residents. LPA reviewed 5 staff files with no discrepancies observed. All staff files reviewed had the required annual training. LPA reviewed 5 resident files. LPA observed that 2 out of the 5 resident files (Resident 1 and Resident 2) did not have a current medical assessment (LIC602A). LPA inspected 5 resident medications. No discrepancies observed. No obstacles or hazards were noted inside or outside of the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/21/2024
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Deficiencies are being cited per title 22 Division 6 of the California Code of Regulations on the attached LIC 809D. An exit interview was conducted with the Executive Director and a copy of the report provided along with appeal rights.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/21/2024 02:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 5 resident files (Resident 1 and Resident 2) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2024
Plan of Correction
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Licensee agrees to have new updated medical assessments completed for Resident 1 and Resident 2 and to submit the completed medical assessments to the LPA by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
LIC809 (FAS) - (06/04)
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