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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 02:26:43 PM


Document Has Been Signed on 06/21/2024 02:26 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lindsay SchroederTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit to follow up on an incident report (LIC 624) submitted to the Agency on June 5, 2024. LPA met with Executive Director Lindsay Schroeder and explained the reason for the visit. The incident report stated Resident 1 (R1) had an unexplained injury to their head. Staff reported there were no witnesses to the incident. Staff called 911, paramedics arrived and transported the resident to the hospital. The responsible party (RP) and R1's primary care physician (PCP) were notified. R1 returned to the facility the same day with no new orders. LPA interviewed staff and R1. LPA toured the dining room and R1's room.

LPA observed no health concerns during the visit. No deficiencies observed during the case management visit.

No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided to the Executive Director.
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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