Inspection Reports for
Serra Highlands Senior Living

The complaint investigation was substantiated for the allegation of improper staff training due to lack of documented medication training for med-techs. The allegation of medication mishandling was unsubstantiated after review of medication administration records and staff interviews.

The allegation that staff were not properly trained was substantiated due to med-techs not completing required initial and annual medication training. The allegation that staff mishandled residents' medications was unsubstantiated based on medication administration records and staff interviews.

The facility was found deficient for failing to provide documentation that a 30-day eviction notice was submitted to the licensing agency, posing a potential health and safety risk to residents.

The complaint investigation was substantiated for the allegation that staff did not properly maintain residents' rooms, specifically Resident 1's room having a urine odor. Other allegations including unmet bathing needs, improper feeding, unmet planned activities, and lack of privacy were unsubstantiated.

The investigation substantiated the allegation that staff did not properly maintain residents' rooms, specifically noting a urine odor in Resident 1's room. Other allegations regarding bathing needs, feeding, planned activities, and privacy were found to be unsubstantiated based on interviews, observations, and document reviews.

The complaint investigation was substantiated for the allegation that Staff 1 used profanity towards Resident 1. Other allegations regarding staff response to call buttons, assistance to residents, and room temperature were unsubstantiated.

The allegation that staff used profanity towards a resident was substantiated based on interviews and evidence. The allegations regarding untimely response to call buttons, failure to assist residents, and uncomfortable room temperatures were unsubstantiated due to insufficient evidence. The facility was cited for a deficiency related to personal rights of residents.

The visit was complaint-related due to a medication error involving Resident 1. The error was substantiated as the facility failed to provide medication as prescribed.

The facility failed to provide Resident 1's medication as prescribed by the physician when a med-tech administered a 50mg capsule of Pregabalin instead of the prescribed 75mg capsule. The med-tech responsible is no longer employed at the facility.

The complaint investigation was substantiated for the allegation that staff did not ensure resident's medical records were up to date, specifically that Resident 1 had not seen a primary care physician since 2021. Other allegations were unsubstantiated due to lack of preponderance of evidence.

The investigation substantiated that a resident (R1) had not received an annual routine physician visit since 9/2021, violating California Code of Regulations. Other allegations including food service provision, medical appointment attendance, staff training, restroom supplies, and retention of a resident requiring higher care were found unsubstantiated based on interviews, record reviews, and observations.

The facility was generally well maintained with adequate supplies and safety equipment, but two Type A deficiencies were identified: hot water temperatures were below the required 125°F in most tested rooms, and four staff members lacked criminal background clearances.

The complaint investigation was triggered by allegations including inaccessible dresser and uncomfortable temperature, which were substantiated, and allegations of improper resident transfer resulting in injury, failure to seek timely medical attention, and failure to transport resident to medical appointment, which were unsubstantiated.

The investigation substantiated that a resident's dresser was inaccessible due to its placement against the bed and that the facility did not maintain a comfortable temperature in some areas due to non-functioning heating units, with space heaters provided as a temporary measure. Another set of allegations regarding improper resident transfer and delayed medical attention were found unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was substantiated for the allegation that three residents eloped due to lack of supervision. Other allegations were unsubstantiated. An immediate civil penalty of $500 was assessed for absence of supervision.

The allegation that three residents eloped due to lack of supervision was substantiated with evidence of one resident leaving unassisted once. An immediate civil penalty of $500 was issued for absence of supervision. Other allegations including administrator presence, broken toilet, nutritional needs, staffing levels and training, and notification of corporate changes were found to be unsubstantiated based on interviews, observations, and document reviews.

The facility was found to be clean, in good repair, and in compliance with Title 22 regulations. No citations were issued, and licensure is recommended. Minor issues were noted such as soap dispensers not dispensing properly and insufficient linen supply, but corrective actions were planned.

The facility was cited for two Type B violations related to advertisement and license number disclosure, and transferability of license. The facility was advertising under a different name without a valid license and failed to notify residents or their representatives in writing about the transfer of the property or business.

The visit was complaint-related, triggered by observations that the facility was advertising as a licensed RCFE without having an approved license. The complaint was substantiated by the deficiencies cited.

The facility was found to be advertising as Serra Highlands Senior Living without a valid RCFE license and failed to notify residents or their representatives in writing about the transfer of the property or business as required by regulation. These deficiencies pose potential health, safety, or personal rights risks to clients in care.