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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005946
Report Date: 10/01/2025
Date Signed: 10/01/2025 04:35:08 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
08/18/2022 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220818123025
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: 57DATE:
10/01/2025
UNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:Rebecca Langdon, Lindsay SchroederTIME COMPLETED:
04:59 PM
ALLEGATION(S):
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Staff are not meeting residents needs
Staff did not safeguard residents personal belongings
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 Operations Specialist Rebecca Langdon and Exeuctive Director Lindsay Schroeder and explained the reason for the visit.

The investigation into the allegation, staff are not meeting residents needs, revealed the following. It was alleged that Resident 1 (R1) was not having their hygiene and grooming needs met. It was reported that when visitors went to visit R1, R1 was not groomed and not completely dressed. No dates or times were provided as to when this incident occurred. The incident was reported to have, happened once. LPA interviewed the Director of Nursing who reported that R1 has their needs met and is dressed and groomed properly every day. It was reported that R1 is not being showered as often as needed. 5 out of 5 staff interviewed reported that R1 is showered twice or three times a week based on their need.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
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 5
Control Number 22-AS-20220818123025
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: 10/01/2025
NARRATIVE
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The Director of Nursing reported that all residents are showered at least twice a week, but some residents require 3 showers a week and they are provided as needed. It was reported that R1 was not provided their incontinent briefs (briefs). 3 out of 5 staff reported that sometimes residents, including R1, take them off. 5 out of 5 staff reported that they attempt to have the residents put the briefs back on. 5 out 5 staff interviewed reported that they never force a resident to wear something they don’t want to wear. The Director of Nursing reported that they do their best to keep residents dressed but sometimes residents want to change their clothes or put something else on, and staff are instructed to assist residents and to make sure they are wearing clean clothing. 5 out of 5 staff interviewed denied the allegation and reported that all of the residents are being properly cared for. 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 did not safeguard residents personal belongings, revealed the following. It was reported that Resident 1’s (R1’s) bed sheets, hair dryer, handbag, clothes and coat went missing. No other specific details were provided. The Executive Director and Director of Nursing reported that no missing items were reported. 5 out of 5 staff members interviewed reported that they were unaware that R1 had any missing items. 5 out 5 staff reported that if a resident has missing bed sheets they replace them. The Director of Nursing reported that some residents provide their own sheets and all laundry for each resident is done separately so nothing goes missing. The Director of Nursing reported that if a resident’s sheets are being washed, clean sheets will be provided by the facility until their sheets are laundered and ready to be put on the resident’s bed. A review of R1’s inventory list shows R1’s responsible party declined to have any of R1’s property inventoried at the time of move in. It is unknown what items R1 moved in with and had in their possession. None of the evidence gathered supports the allegation, therefore the allegation is deemed unsubstantiated, meaning that 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: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/18/2022 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220818123025

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: 57DATE:
10/01/2025
UNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:Rebecca Langdon, Lindsay SchroederTIME COMPLETED:
04:59 PM
ALLEGATION(S):
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Facility has not done a yearly review of residents care and services plan
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 Operations Specialist Rebecca Langdon and Executive Director Lindsay Schroeder and explained the reason for the visit.

The investigation into the allegation, facility has not done a yearly review of residents care and services plan, revealed the following. Resident 1 (R1) moved into the facility on September 27, 2021 and moved out of the facility on September 1, 2023. It was reported that R1 did not have the annual reappraisal (care plan) and did not have their needs and care plan completed timely. A review of records shows that R1 had their initial care plan (appraisal) completed on September 27, 2021, at the time of their move in. The next care plan (reappraisal) was completed on December 20, 2021. R1’s next care plan was completed on January 3, 2023 which is one year and 2 weeks after the previous care plan. Care plans (reappraisals) are required to be completed as frequent as necessary or once every 12 months.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20220818123025
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: 10/01/2025
NARRATIVE
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Based on the evidence gathered, the preponderance of evidence standard has been met therefore the allegation is substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20220818123025
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: 10/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2025
Section Cited
CCR
87463(a)
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The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first... This requirement is not being met as evidenced by,
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Licensee agrees to have staff responsible for completing care plans (reappraisals) trained on CCR 87463 and to submit proof of training to LPA by the POC due date.
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R1's last care plan (reappraisal) was completed on January 3, 2023, which is 12 months and 2 weeks after the previous care plan (reappraisal) which poses a potential, health and safety risk to the Resident (R1).
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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: 10/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5