Inspection Reports for Serra Sol Memory Care

The inspection was an unannounced complaint investigation visit triggered by allegations including staff not meeting residents' needs, staff not safeguarding residents' personal belongings, and failure to conduct a yearly review of residents' care and services plans.

The investigation found the allegations that staff were not meeting residents' needs and not safeguarding personal belongings to be unsubstantiated due to lack of evidence. However, the allegation that the facility failed to conduct a timely yearly review of residents' care and services plans was substantiated, with a care plan reappraisal completed over 12 months late, posing a potential health and safety risk.

The complaint investigation was unannounced and involved allegations that staff were not meeting residents' needs, not safeguarding residents' personal belongings, and failure to conduct a yearly review of residents' care and services plans. The first two allegations were unsubstantiated, while the third was substantiated. The report states the complaint was received on 08/18/2022 and investigated by Evaluator Joseph Alejandre.

An unannounced complaint investigation visit was conducted in response to allegations that a resident was left in soiled clothing and with fecal matter in fingernails.

The investigation found no evidence to support the allegations. Staff and administration denied the reports, and a review of the resident's records showed no incidents to corroborate the claims. Therefore, the allegations were deemed unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included a resident being left in soiled clothing and with fecal matter in fingernails. No evidence was found to support these claims despite interviews and record reviews.

The inspection was an unannounced complaint investigation visit conducted to address multiple allegations including lack of supervision resulting in a physical altercation, staff yelling at a resident, staff disturbing residents' sleep, CCL poster visibility, failure to notify authorized representatives of medical/medication changes, and lack of supervision resulting in resident AWOL.

The investigation found most allegations unsubstantiated or unfounded except for the allegation of lack of supervision resulting in resident AWOL, which was substantiated. The facility was found to have complied with poster posting requirements and notification of medical changes. The facility staff acted appropriately during the physical altercation incident. A citation was issued for the substantiated elopement due to lack of supervision.

The complaint investigation addressed allegations of lack of supervision resulting in a physical altercation, staff yelling at a resident, staff disturbing residents' sleep, CCL poster not visible to residents, failure to notify authorized representatives of medical/medication changes, and lack of supervision resulting in resident AWOL. Most allegations were unsubstantiated or unfounded except the AWOL incident which was substantiated with a citation issued.

An unannounced visit was conducted to investigate a complaint alleging that staff did not provide adequate supervision, resulting in a resident sustaining a fall.

The investigation found that the allegation was unfounded. Records showed no resident with the reported fall on June 22, 2025; the fall was likely a staff member who fell on that date. Witnesses could not confirm if the person who fell was a resident or staff.

The complaint alleged inadequate staff supervision leading to a resident fall on June 22, 2025. The allegation was deemed unfounded based on evidence including staff schedules, progress notes, and interviews.

Licensing Program Analyst Joseph Alejandre made an unannounced visit to conduct the required annual inspection of the facility.

The facility was found to be in compliance with all licensing requirements. No deficiencies were cited. The facility was clean, well-maintained, and had all required supplies and safety equipment. Staff files, resident files, and medications were reviewed with no discrepancies observed.

An unannounced complaint investigation visit was conducted following complaints that facility staff were not reporting incidents as required and that staff were serving expired food to residents.

The investigation substantiated that the facility failed to report an unknown injury incident involving a resident and that expired food (12 cans of soup) was stored in the kitchen. The facility staff disposed of the expired food. Another allegation regarding washing machines was unsubstantiated.

The complaint investigation was substantiated for failure to report an incident involving a resident's unknown injury and for serving expired food. The allegation regarding malfunctioning washing machines was unsubstantiated.

An unannounced visit was conducted to investigate a complaint received on 2025-01-13 regarding the facility's failure to provide requested documents.

The investigation found that the facility did not provide requested records for Resident 1 despite acknowledging the request, resulting in a substantiated allegation and a cited deficiency under California Code of Regulations Title 22.

The complaint was substantiated. The facility failed to provide requested documents for Resident 1 despite multiple requests and acknowledgment of the request. The Executive Director confirmed the delay and committed to providing the documents by January 28, 2025.

An unannounced proof of correction visit was conducted to verify correction of deficiencies cited during the annual inspection.

The Licensing Program Analyst verified that two residents who previously lacked current physician reports now have updated reports. No deficiencies were cited during this visit.

Licensing Program Analyst Joseph Alejandre conducted an unannounced required annual inspection of the Serra Sol facility to assess compliance with regulatory standards.

The facility was generally found to be clean, organized, and operational with proper safety measures in place. However, deficiencies were cited due to two out of five resident files lacking current medical assessments as required for residents with dementia.

Licensing Program Analyst Joseph Alejandre made an unannounced case management visit to follow up on an incident report submitted on June 5, 2024, regarding a resident's unexplained head injury.

No health concerns or deficiencies were observed during the visit. The resident was transported to the hospital and returned the same day with no new orders. No deficiencies are being cited as a result of this visit.

An unannounced visit was conducted to investigate a complaint alleging that staff did not prevent a resident from developing a pressure injury while in care.

The investigation found no evidence that the staff caused any injury to the resident or that the resident had a pressure injury. The allegation was deemed unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that staff failed to prevent a resident from developing a pressure injury. The investigation included review of hospital discharge paperwork, facility notes, and interviews. The allegation was unsubstantiated as no evidence confirmed the injury or staff fault.

An unannounced complaint investigation visit was conducted following a complaint received on 2024-03-01 regarding the facility's failure to provide a resident's complete medical records to the resident's authorized representative.

The investigation substantiated that the facility did not provide all requested records, specifically the resident's medication administration records and resident notes, to the authorized representative. The facility provided 147 pages of records but omitted these critical documents, posing a potential health and safety risk.

The complaint was substantiated based on the preponderance of evidence standard. The allegation was that the facility failed to provide the complete medical records to the resident's authorized representative, which was confirmed during the investigation.

An unannounced complaint investigation visit was conducted following a complaint received on 08/18/2022 alleging that staff do not assist residents with showering and grooming.

The investigation found no evidence to support the allegations. Residents were observed to be groomed and showered regularly, hygiene supplies were available, and staff reported residents are showered at least twice a week. The allegations were deemed unsubstantiated.

The complaint allegations that staff do not assist residents with showering and grooming were investigated and found to be unsubstantiated due to lack of evidence.

The visit was an unannounced follow-up to an incident report received on 2022-08-09 concerning a resident becoming aggressive toward staff and another resident.

The facility responded appropriately by separating the residents, calling 911, notifying the family, and adjusting the resident's medication. No injuries were noted and no deficiencies were cited as a result of this visit.

An unannounced post licensing inspection (mitigation) was conducted to evaluate the facility's compliance following licensing.

The facility was found to be in compliance with no deficiencies observed. The environment was clean, safe, and well-maintained, with proper furnishings, secured medication storage, and functional fire safety equipment.

The visit was conducted as a pre-licensing inspection for a Residential Care Facility for the elderly specializing in residents with Dementia.

The facility was found to be ready for licensure with no observed obstacles or hazards, operational safety systems, clean and functional bathrooms and kitchen, and compliance with Title 22 Division 6 of the California Code of Regulations. Fire clearance was approved by the Orange County Fire Authority.

Initial licensing evaluation conducted via telephone call with the applicant and administrator to verify identity and confirm understanding of Title 22 regulations and facility operation requirements.

The applicant and administrator successfully completed the COMP II component, demonstrating understanding of licensing requirements, staff qualifications, program policies, and application documentation. No deficiencies or violations were noted in the report.