Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally good compliance with regulations. The most recent report from October 1, 2025, did cite one deficiency for a late annual care plan reappraisal, which posed a potential health and safety risk. Earlier substantiated issues included failure to provide requested resident documents, storing expired food, and a resident elopement due to lack of supervision, but these were isolated and not repeated in recent inspections. The facility showed improvement with the June 30, 2025 annual inspection finding no deficiencies. Overall, the main themes among deficiencies involved documentation and supervision, with no fines or enforcement actions listed in the available reports.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 57
Capacity: 70
Deficiencies: 1
Oct 1, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to complete the annual care plan reappraisal timely, with the last reappraisal completed 12 months and 2 weeks after the previous one, posing a potential health and safety risk to the resident. | Type B |
Report Facts
Capacity: 70
Census: 57
Deficiency count: 1
Plan of Correction Due Date: Oct 10, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Janelle Lopez | Administrator | Facility Administrator mentioned in report header |
| Rebecca Langdon | Operations Specialist | Met with Licensing Program Analyst during investigation |
| Lindsay Schroeder | Executive Director | Met with Licensing Program Analyst during investigation |
| Director of Nursing | Interviewed regarding resident care and allegations |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 70
Deficiencies: 0
Aug 13, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 70
Census: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Lindsay Schroeder | Executive Director | Met with Licensing Program Analyst during the investigation and provided information |
| Sheila Santos | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 70
Deficiencies: 1
Aug 13, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Care Of Persons With Dementia - Facility staff shall ensure the continued safety of residents if they wander away from the facility. Resident 1 left the facility unattended on June 23, 2021 for approximately 30 minutes which poses an immediate health, safety and personal rights risk to residents in care. | Type A |
Report Facts
Capacity: 70
Census: 61
Deficiencies cited: 1
Plan of Correction Due Date: Aug 14, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Lindsay Schroeder | Executive Director | Met with Licensing Program Analyst during investigation and provided information |
| Janelle Lopez | Administrator | Facility administrator mentioned in report header |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 70
Deficiencies: 0
Jun 30, 2025
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that staff did not provide adequate supervision, resulting in a resident sustaining a fall.
Findings
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.
Complaint Details
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.
Report Facts
Staff working on date of alleged fall: 13
Facility capacity: 70
Resident census: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation visit |
| Lindsay Schroeder | Administrator / Executive Director | Met with Licensing Program Analyst during investigation |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 60
Capacity: 70
Deficiencies: 0
Jun 30, 2025
Visit Reason
Licensing Program Analyst Joseph Alejandre made an unannounced visit to conduct the required annual inspection of the facility.
Findings
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.
Report Facts
Hot water temperature range: 109
Hot water temperature range: 112.6
Emergency disaster drill date: Jun 26, 2025
Fire alarm/fire detection system inspection date: Apr 5, 2024
Number of staff files reviewed: 5
Number of resident files reviewed: 6
Number of resident medications inspected: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the inspection and made the unannounced visit |
| Lindsay Schroeder | Executive Director / Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 70
Deficiencies: 2
Mar 25, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to submit a written report to the licensing agency within seven days of an incident threatening resident welfare, safety, or health. | Type B |
| Expired food (12 cans of soup) stored in the kitchen food storage area posing a potential health and safety risk. | Type B |
Report Facts
Expired food items observed: 12
Facility capacity: 70
Resident census: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lindsay Schroeder | Administrator | Facility administrator met during investigation and involved in findings |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 70
Deficiencies: 1
Jan 23, 2025
Visit Reason
An unannounced visit was conducted to investigate a complaint received on 2025-01-13 regarding the facility's failure to provide requested documents.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide requested documents within two business days as required, posing a personal rights risk to residents. | Type B |
Report Facts
Capacity: 70
Census: 50
Deficiency Type: 1
Plan of Correction Due Date: Jan 31, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation and cited the deficiency |
| Lindsay Schroeder | Executive Director | Met with Licensing Program Analyst and verified information regarding the document request |
Inspection Report
Follow-Up
Census: 42
Capacity: 70
Deficiencies: 0
Sep 4, 2024
Visit Reason
An unannounced proof of correction visit was conducted to verify correction of deficiencies cited during the annual inspection.
Findings
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.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lindsay Schroeder | Executive Director | Met with Licensing Program Analyst during the visit and discussed correction of deficiencies. |
| Joseph Alejandre | Licensing Program Analyst | Conducted the unannounced proof of correction visit. |
Inspection Report
Annual Inspection
Census: 40
Capacity: 70
Deficiencies: 1
Jun 21, 2024
Visit Reason
Licensing Program Analyst Joseph Alejandre conducted an unannounced required annual inspection of the Serra Sol facility to assess compliance with regulatory standards.
Findings
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Two out of five resident files (Resident 1 and Resident 2) did not have a current medical assessment (LIC602A) as required for residents with dementia. | Type B |
Report Facts
Residents without current medical assessment: 2
Total resident files reviewed: 5
Staff files reviewed: 5
Capacity: 70
Census: 40
Plan of Correction Due Date: Jul 3, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Lindsay Schroeder | Executive Director / Administrator | Met with Licensing Program Analyst during inspection |
| Sheila Santos | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Census: 40
Capacity: 70
Deficiencies: 0
Jun 21, 2024
Visit Reason
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.
Findings
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.
Report Facts
Incident report date: Jun 5, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the unannounced case management visit |
| Lindsay Schroeder | Executive Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 70
Deficiencies: 0
May 8, 2024
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 70
Census: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation visit |
| Lindsay Schroeder | Administrator / Executive Director | Met with during investigation and provided information |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 70
Deficiencies: 1
Mar 11, 2024
Visit Reason
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.
Findings
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.
Complaint Details
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.
Deficiencies (1)
| Description |
|---|
| Facility did not provide Resident 1's medication administration records and resident notes as part of the requested complete medical records. |
Report Facts
Capacity: 70
Census: 48
Pages of records provided: 147
Plan of Correction Due Date: Mar 18, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Lindsay Schroeder | Executive Director | Met with the Licensing Program Analyst during the investigation |
| Janelle Lopez | Administrator | Verified the incomplete records provided to the authorized representative |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 70
Deficiencies: 0
Aug 26, 2022
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 70
Census: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation visit |
| Susie Peterson | Executive Director | Interviewed during the investigation |
| Khatera Bahadory | Director of Nursing | Interviewed during the investigation |
| Luz Adams | Licensing Program Manager | Named in report signature and oversight |
Inspection Report
Follow-Up
Census: 36
Capacity: 70
Deficiencies: 0
Aug 10, 2022
Visit Reason
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.
Findings
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.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susie Peterson | Executive Director | Met with Licensing Program Analyst during the visit and involved in incident follow-up. |
| Khatera Bahadory | Director of Nursing | Met with Licensing Program Analyst during the visit and involved in incident follow-up. |
| Joseph Alejandre | Licensing Program Analyst | Conducted the unannounced follow-up visit. |
Inspection Report
Original Licensing
Census: 25
Capacity: 70
Deficiencies: 0
Mar 23, 2022
Visit Reason
An unannounced post licensing inspection (mitigation) was conducted to evaluate the facility's compliance following licensing.
Findings
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.
Report Facts
Hot water temperature range: Measured between 107.4 and 113.4 degrees Fahrenheit
Food supply duration: 2
Food supply duration: 7
Fire drill date: Last fire drill conducted on 2022-02-28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the post licensing inspection |
| Susie Peterson | Facility Administrator met during inspection |
Inspection Report
Original Licensing
Capacity: 70
Deficiencies: 0
May 27, 2021
Visit Reason
The visit was conducted as a pre-licensing inspection for a Residential Care Facility for the elderly specializing in residents with Dementia.
Findings
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.
Report Facts
Resident rooms inspected: 58
Hot water temperature range: 114.6
Hot water temperature range: 120
Fire clearance approval date: May 4, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the pre-licensing inspection and authored the report |
| Janelle Lopez | Administrator | Facility administrator mentioned in the report |
Inspection Report
Original Licensing
Capacity: 70
Deficiencies: 0
May 19, 2021
Visit Reason
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.
Findings
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.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janelle Lopez | Administrator | Named as facility administrator participating in the licensing evaluation. |
| Richard Westin | Met with during the visit along with the administrator. | |
| Julia Kim | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Nicole Rouse | Licensing Program Analyst | Named as Licensing Program Analyst on the report. |
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