Serra Sol.

Regarding the allegation, staff allowed resident to leave the facility without staff supervision, the following has been concluded: The Department conducted eight resident interviews. Eight out of the eight residents interviewed denied the allegation and stated that they have never been left without staff supervision. The Department conducted six staff interviews. Six out of the six staff interviewed denied the allegation and reported no knowledge of an incident in which a resident was able to leave the facility without staff supervision. Regarding the allegation, staff did not provide nutritious meals to residents in care, the following has been concluded: During the investigation, the Department inspected the food that was being provided to the residents in care. The Department observed the facility provided various fruit and vegetable options, as well as different protein sources. The Department observed the food to be of good quality and to be free of any mold. The Department conducted eight resident interviews. Eight out of the eight residents interviewed denied the allegation and reported that they were satisfied with the food that is served to them. The Department conducted six staff interviews. Six out of the six staff interviewed also denied the allegation. Regarding the allegation, staff did not store food in a safe and healthful manner, the following has been concluded: The Department inspected the facility's food storage areas during it's visits on November 26, 2025, and on April 17, 2026. During both visits, the Department observed food to be stored in appropriate containers and to be labeled. The Department observed the food to be free of any mold and observed that the facility takes all the necessary precautions to store food safely. The Department also observed the facility's kitchen areas to be clean. The Department conducted six staff interviews. Six out of the six staff interviewed denied the allegation and stated that food is stored in a safe manner. Regarding the allegation, staff did not follow proper reporting requirements, the following has been concluded: The Department conducted six staff interviews. Six out of the six staff interviewed denied the allegation and stated that the facility has always followed the reporting requirements. The six staff interviewed also stated that the appropriate parties, such as families and doctors, are always notified when an incident occurs. CONTINUED ON LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the five allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Christine Greenway and a copy of the report was provided.

S1 reported that R1's responsible party arrived at the facility shortly after the call and took R1 to urgent care. S1 reported that normally they would wait for the physician or nurse practitioner to respond with a prescription or over the counter (OTC) medication to administer to the resident but R1's responsible party decided to take R1 to urgent care and when they returned they had prescriptions and medications for R1 to treat R1. The Wellness Director reported they were notified about the issue and spoke to R1's responsible party who informed them all the facility had to do was administer the medication. The Wellness Director reported that the prescriptions and medication prescribed for R1 were all verified so they administered the medication. The facility followed their procedure for the incident and contacted R1's PCP and were waiting for a response from R1's PCP on how to proceed. S1 and the Wellness Director reported it was not an emergency that required hospitalization or emergency services so an ambulance and/or 911 were not called. R1's responsible party verified that they took R1 to urgent care right after receiving the call from the facility. A review of R1's progress notes shows R1 saw their nurse practitioner on April 1, 2025, at the facility and R1 was observed to have swollen feet and a swollen toe. Medications and blood tests were ordered for R1 after the visit. On April 3, 2025 the blood draw was completed and on April 4, 2025 the new medications arrived and administered to R1. There was no mention of any swelling for R1 mentioned prior to April 1, 2025. On April 22, 2025 R1 was observed to have constipation. S1 and the Wellness Director informed R1's PCP and responsible party. S1 and the Wellness Director reported that the responsible party requested they give R1 prune juice. S1 reported they complied with the request. S1 reported that the issue wasn't an emergency and R1 did not report they were in pain so they waited for R1's PCP to respond to the report. The Wellness Director reported that R1's responsible party came to the facility to visit R1. The Wellness Director reported that the responsible party told them that R1 had a bowel movement and they were fine so they were taking R1 back home. The Wellness Director reported that R1 never returned to the facility and they never heard from R1 or they responsible party again. In each instance R1 received the proper medical care required and the facility responded in the proper manner and sought non-emergency medical care. Based on the evidence gathered 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 ordered medications for resident in care without proper authorization, revealed the following. It was reported that the Wellness Director ordered medications for R1 and had the orders filled without proper authorization on January 6, 2025. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The Wellness Director denied the allegation and reported that they met with R1's responsible party on January 6, 2025 and informed them R1 was displaying exit seeking behavior and was having a hard time adjusting to their new environment and suggested visiting R1 and having some more items from home in their room. 2 out of 2 med-techs interviewed and the Wellness Director reported that they only follow doctor's orders and don't recommend medications and suggest responsible parties should contact the physician if they have questions or concerns about medications. A review of records shows R1 moved in (December 31, 2024) with 8 prescribed medications and after seeing their nurse practitioner after move in, they were prescribed 1 additional medication with an order date of January 12, 2025. R1's was prescribed 17 different medications at the time move out. A review of records shows all medications were prescribed by a physician or nurse practitioner. None of the evidence gathered supports the allegation. Based on the evidence gathered 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 report resident's incidents to appropriate parties, revealed the following. It was reported that R1's responsible party was not properly notified about incidents concerning R1 and that the facility didn't report the incidents to Community Care Licensing (CCL). The first incident was in January 2025 and R1 had diarrhea for multiple days, the second incident R1 had a swollen toe and feet on April 1, 2025 and the third incident on April 22, 2025, R1 had constipation. R1's responsible party verified they were notified about each incident. The Wellness Director and Staff 1 (S1) reported that none of the incidents were an emergency and R1 reported no pain. The Wellness Director and S1 reported that no of the incidents threatened R1's health, safety or well being. A review of records shows each incident was resolved and the first 2 incidents medication was ordered and administered within days of the report with no reported issues. Based on a review of facility records and California Code of Regulations, Title 22, (CCR) 87211 reporting requirements, none of the reported incidents rose to the level of submitting an incident report because all of the incidents were minor and the welfare, safety or health of R1 was not threatened. Based on the evidence gathered 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. An exit interview was conducted and a copy of the report provided.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced case management visit. The Agency (Community Care Licensing) received a report on February 20, 2026, that there was no staff at the facility and the residents had no supervision. LPA met with Administrator Christine Greenway and explained the reason for the visit. The Administrator reported that 3 caregivers did not report to work for their 6:00 am shift, but the overnight staff covered the shifts until other staff members were called in to work. The Administrator reported that at no time were residents left unattended. LPA and the Administrator toured the facility. LPA observed 17 staff members at the facility during the visit of which 4 are care staff. The Administrator reported that they are arranging for additional care staff through an agency and are actively hiring additional care staff. No deficiencies observed during the visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.

The investigation into the allegation, facility does not have complete resident records, revealed the following. It was reported that Resident 2 (R2) did not have a care plan and no medication records. A review of facility records shows R2 moved in September 24, 2021 and had a care plan dated September 23, 2021 and a care plan dated October 6 and a medication list for September 2021. LPA reviewed 3 other resident files for Resident 1 (R1), Resident 3 (R3) and Resident 4 (R4). No discrepancies observed. Based on the evidence gathered the allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The investigation into the allegation, facility did not have a resident appraised, revealed the following. It was reported that R2 was not appraised. R2 moved into the facility September 24, 2021. A review of R2's records shows R2 was assessed on September 23, 2021 prior to move in and assessed on October 6, 2021 after they moved in the facilty. Based on the evidence gathered the allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The investigation into the allegation, facility staff is not properly trained, revealed the following. It was reported that Staff 1 (S1) had no training, experience or certifications. A review of records shows S1 had over 24 hours of training and 16 hours of on the job training (one on one training with another caregiver) in topics such as, care of residents with Dementia, basic care skills, providing medication assistance, resident rights and CPR certification. A review of 3 other caregiver files showed all 3 caregivers had 40 hours of initial training. Based on the evidence gathered the allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of the report provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on the evidence gathered 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, facility staffing is not sufficient to meet resident's needs, revealed the following. It was reported that a lack of staff has resulted in multiple falls from residents. It also was reported that Resident 5 (R5) passed away at the facility. A review of records shows, R5 was sent to the hospital on July 9, 2021 and never returned to the facility. R5 passed away at the hospital on July 15, 2021. A review of the staff schedule for October and September 2021 show 18 caregivers and med-techs. 2 caregivers and 1 med-tech are scheduled for the AM shift (6am - 2pm) and PM shift (2pm-10pm). 1 caregiver and 1 med-tech for NOC shift (10pm - 6am). The Executive Director reported they are in the process of hiring more staff but at this time they only have 14 residents so there is enough staff to care for all the residents. 5 out of 5 staff reported there is enough staff to meet the needs of the residents. A review of incident reports received for September and October 2021 show only 2 incidents reports were received from the facility. One report noted a resident was found sitting on the floor and the other report noted a resident was lethargic. Neither report raised any concerns for the Agency and did not require follow up. Based on the evidence gathered 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. An exit interview was conducted and a copy of the report provided.

out of 3 Med-techs interviewed reported R1 receives all their medication as prescribed. Witness 1 (W1) reported that R1 received more than the prescribed amount of melatonin, no dates or times were provided. W1 would not answer how they knew R1 received the wrong amount melatonin. There is no evidence to support 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 ensure that resident ingested medications, revealed the following. It was reported that med-techs would give R1 their medication in a paper cup and then walk away and did not ensure R1 actually took the medication. 3 out of 3 med-techs interviewed denied the allegation. R1 did not respond to LPA’s questions. W1 reported that they never witnessed a med-tech walk away from R1 before they took the medication. 3 out of 3 caregivers interviewed reported they had never witnessed a med-tech give a resident medication and walk away before the resident took the medication. 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, Resident's records are not accurate, revealed the following. It was reported that R1’s resident information sheet (face sheet) had inaccurate information on it. No details were provided. LPA reviewed the information and verified the resident information, and the responsible party information was correct along with physician information. The Executive Director reported the information is correct to the best of their knowledge. R1’s responsible party would not verify any medical information. It is unclear what information was not accurate. Based on the evidence gathered 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 is not communicating with resident's representatives in a timely manner, revealed the following. It was reported that the facility staff would not communicate with R1’s family regarding the status and condition of R1 or to provide requested documents like observation notes for R1. A review of incident reports for the facility for September and October 2021 shows only 2 incident reports submitted to the Agency and neither incident involved R1. There is no regulation regarding communicating with a responsible party unless it involves an incident that threatens the health, safety and welfare of a resident. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The Executive Director stated that the Responsible Party/Power of Attorney for R1 has not requested any documents so none have been provided, and any other requests would be denied without the Power of Attorney’s permission. R1’s Power of Attorney reported that they have not requested any records for R1 and have no issues with communication with the facility. Based on the evidence gathered 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 respond to the front door exit alarm in a timely manner, revealed the following. It was reported that Witness 2 (W2) exited the front door of the facility and the door alarm sounded and no staff responded to the door alarm. W1 reported that no one came to check the door. No date or time was provided for this incident. 1 out of 3 caregivers interviewed reported that they remember the incident. Staff 6 (S6) reported that they remember one afternoon (doesn’t remember the date) they saw R1’s family leaving the interior of the facility and exiting into the main lobby which has the front door to enter and exit the facility. S6 reported that the front door to the facility is not alarmed and does not make a sound when people open it. S6 reported that R1’s family pushed on the door leading to the lobby (which is delayed egress) and it opened, and the alarm went off and they left. S6 reported they were down the hall and saw that no residents were exiting and saw the door close and they walked up to the door and made sure it was secured. S6 stated that by the time they got to the door R1’s family had left. Based on the evidence gathered 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 are serving food that does not meet individual needs, revealed the following. It was reported that the facility served R1 food that was unhealthy, high in salt and sugar and did not meet the needs of R1. A review of R1’s records show R1 was not prescribed a special diet. A review of the facility menu shows the facility is following Title 22 guidelines and the admission agreement which states that 3 nutritionally balanced meals along with snacks will be provided. LPA toured the kitchen and observed a two day supply of perishable food and a seven day supply of non-perishable food and observed all 4 food groups and observed fresh produce, dairy and proteins along with fresh bread and cereals. Based on the evidence gathered 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. An exit interview was conducted and a copy of the report provided.

The investigation into the allegation, Resident left with fecal matter in fingernails, revealed the following. No time or date was provided as to when this occurred. R1 moved into the facility on December 7, 2021 and moved out of the facility on November 6, 2022. W1 reported that when they visited R1 they had fecal matter on/in their fingernails. No photographic evidence was provided. At the time of the initial visit R1 had moved out of the facility. W1 reported that R1's hands were probably like that for days. 5 out of 5 staff interviewed denied this report. The Executive Director reported that no one reported any issues with R1. The Wellness Director reported that no issues with R1 have been reported by staff or by any visitors. A review of R1’s records (progress notes) show no incidents to corroborate W1’s report. No evidence was gathered to support 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. An exit interview was conducted and a copy of the report provided.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Executive Director (ED) Lindsay Schroeder and explained the reason for the visit. Lindsay Schroeder's Administrator's Certificate expires on January 1, 2027. Facility is a two story building with 2 courtyards (one on each floor) and surrounding parking lot. Facility is approved for delayed egress exits and a secured perimeter. LPA and ED toured the facility. LPA observed the See Something, Say Something poster (PUB 475) posted in the entry way of the facility. LPA observed the kitchen is clean and organized. There is a two day supply of perishable food and a seven day supply of non-perishable food on-hand in the kitchen. LPA observed that the refrigerators and the freezers had temperature logs posted on them. The refrigerators and freezers were at the required temperatures. LPA observed the facility has an ample supply of perishable and non-perishable food, but does not have a 3 day emergency supply of food. Facility does have a 3 day supply of emergency water. LPA and ED toured 6 resident rooms on the first and second floors. All resident rooms had the required furnishings and bed linens. All resident bathrooms were clean and operational. The hot water in the 6 resident rooms inspected measured between 109.0 degrees Fahrenheit to 112.6 degrees Fahrenheit. LPA observed residents watching a musical performance in the dining room. There is an activity room with games and puzzles and a TV room for residents. There is an outdoor courtyard on each floor with shaded seating for residents to sit outside. There are fire extinguishers on each floor and all fire extinguishers are fully charged. LPA observed an emergency evacuation chair at the top of the stairwell. The last emergency disaster drill was conducted on June 26, 2025. The delayed egress exits tested operational. The fire alarm/fire detection system was inspected and tested operational on April 5, 2024. LPA observed medications are kept secured in a medication cart that is locked in the medication room. LPA observed that the First Aid Kit had all the required elements. Facility has a dedicated computer with internet access for residents. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA reviewed 5 staff files with no discrepancies observed. All staff files reviewed had the required annual training. All staff present at the facility are background cleared and associated to the facility. LPA reviewed 6 resident files. LPA inspected 6 resident medications. No discrepancies observed. No obstacles or hazards were noted inside or outside of the facility. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.

LPA attempted to interview Resident 2 and Resident 3 but neither resident responded to questions from the LPA. Based on the evidence gathered the allegation is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with the Administrator and a copy of the report was provided.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a proof of correction visit for deficiency cited during the annual inspection. LPA was greeted and granted entry by staff. LPA met with Executive Director Lindsay Schroeder and explained the reason for the visit. LPA conducted a document review and obtained copies of resident physician reports. LPA verified the 2 residents who did not have a current LIC 602A (physician's report) that both residents have current updated physician's reports. The deficiency has been cleared. The Executive Director has been provided a proof of correction letter. LPA consulted with the Executive concerning reporting requirements and personal rights. 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.

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.

LPA reviewed R1's physician's report (LIC 602A), needs and care plan, facility notes, hospital discharge paperwork, physician's orders and emergency contact information. R1 had no physician's order to be repositioned every two hours. There is no evidence that the staff caused any injury to R1. There is no evidence to verify that R1 had a pressure injury. LPA was unable to make contact with any of the witnesses except for facility staff. Based on the evidence gathered 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. An exit interview was conducted and a copy of the report provided.