Serra Sol

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not properly address resident's multiple falls at facility.

On May 14, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced for the purpose of conducting a subsequent complaint investigation into the above allegation. LPA was greeted, introduced self, and was granted entry after stating the purpose of the visit to staff. Administrator (Admin) Christine Greenway was contacted via telephone and arrived shortly to assist with the visit. LPA reviewed copies of facility documents including: Resident Roster, Staff Roster, Resident #1's (R1's) Emergency Info & Contact Sheets, Physician's Reports, Admissions Agreement, Service Plan, Incident Reports, Physician Fax Communications, and hospital discharge records. Interviews were successfully conducted with staff and witnesses. Continue to LIC9099-C..... Substantiatedthe state’s words, verbatim · CDSS document, May 14, 2026 · control 22-AS-20260312123306

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff left residents in soiled diapers for an extended period of time Staff allowed resident to leave the facility without staff supervision Staff did not provide nutritious meals to residents in care Staff did not store food in a safe and healthful manner Staff did not follow proper reporting requirements

On April 17, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to continue the investigation into the allegations listed above and deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Christine Greenway was present and assisted on today's visit. During the course of the investigation, the Department interviewed residents, interviewed staff, inspected the facility's food storage areas, reviewed and obtained pertinent documents for this complaint. Regarding the allegation, staff left residents in soiled diapers for an extended period of time, the following has been concluded: The Department conducted eight resident interviews. Eight out of the eight residents interviewed denied the allegation and reported that they were satisfied with the care provided to them. The eight residents also reported that staff are quick to help them if they evthe state’s words, verbatim · CDSS document, Apr 17, 2026 · control 22-AS-20251126091815

Allegation investigated: Staff did not seek medical attention for resident in a timely manner Staff ordered medications for resident in care without proper authorization Staff did not report resident's incidents to appropriate parties

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigaiton into the allegations listed above. LPA met with Administrator Christine Greenway and explained the reason for the visit. The investigation into the allegation, staff did not seek medical attention for resident in a timely manner, revealed the following. It was reported that 3 separate incidents took place involving Resident 1 (R1) that required medical attention and the facility did not seek medical attention for R1 in a timely manner. The first incident was in January 2025 and R1 had diarrhea for multiple days, the second incident R1 had a swollen toe on April 1, 2025 and the third incident on April 22, 2025, R1 had constipation. R1 lived at the facility December 31, 2024 from until May 2, 2025. A review of progress notes for R1 shows that on January 13, 2025 R1 had loose bowel movements and staff assisted R1 with changing their clothes and showering. Staffthe state’s words, verbatim · CDSS document, Apr 15, 2026 · control 22-AS-20250501140051

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Residents left unattended for extended periods of time Facility staffing is not sufficient to meet resident's needs

LIcensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to continue the investigation into the allegations listed above. LPA met with Operations Specialist Becky Langdon and explained the reason for the visit. During the course of the investigation LPA toured the facility, interviewed staff and residents and reviewed faciltiy and resident records. The investigation into the allegation, Residents left unattended for extended periods of time, revealed the following. It was reported that Resident 1 (R1) was left unattended in their bed for 13 hours and no staff checked in on them during the 13 hours they were in bed. No other details concerning this allegation were provided. R1 moved into the facility on September 10, 2021 and went to the hospital on September 22, 2021 and never returned to the facility. R1 has been diagnosed with Dementia. 5 out of 5 staff members interviewed reported that none of residents including R1 have ever been unattended and left in bed for 13the state’s words, verbatim · CDSS document, Oct 23, 2025 · control 22-AS-20211004152934

Allegation investigated: Staff mismanaged resident's medication. Staff did not ensure that resident ingested medications. Resident's records are not accurate. Staff is not communicating with resident's representatives in a timely manner. Staff did not respond to the front door exit alarm in a timely manner. Staff are serving food that does not meet individual needs.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met Operations Specialist Becky Langdon and explained the reason for the visit. During the investigation LPA interviewed staff, residents and witnesses and reviewed facility records. The investigation into the allegation, staff mismanaged resident's medication, revealed the following. It was reported that Resident 1 (R1) was given the incorrect dosage of medication. R1 moved into the facility on September 14, 2021, and moved out of the facility on October 18, 2021. R1 has been diagnosed with Dementia and did not respond to LPA’s questions. A review of R1’s medication records show R1 was prescribed 10 medications. A review of the R1’s medication administration record for September and October 2021, shows R1 was administered medication as prescribed. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 23, 2025 · control 22-AS-20211013122800

Allegation investigated: Staff are not meeting residents needs Staff did not safeguard residents personal belongings

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Operations Specialist Rebecca Langdon and Exeuctive Director Lindsay Schroeder and explained the reason for the visit. The investigation into the allegation, staff are not meeting residents needs, revealed the following. It was alleged that Resident 1 (R1) was not having their hygiene and grooming needs met. It was reported that when visitors went to visit R1, R1 was not groomed and not completely dressed. No dates or times were provided as to when this incident occurred. The incident was reported to have, happened once. LPA interviewed the Director of Nursing who reported that R1 has their needs met and is dressed and groomed properly every day. It was reported that R1 is not being showered as often as needed. 5 out of 5 staff interviewed reported that R1 is showered twice or three times a week based on theirthe state’s words, verbatim · CDSS document, Oct 1, 2025 · control 22-AS-20220818123025

Allegation investigated: Resident was left in soiled clothing Resident left with fecal matter in fingernails

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Executive Director (ED) Lindsay Schroeder and explained the reason for the visit. The investigation into the allegation, Resident was left in soiled clothing. No time or date of the incident was provided. R1 moved into the facility on December 7, 2021 and moved out of the facility on November 6, 2022. Witness 1 (W1) reported that when they visited R1 there was a strong smell of urine, and their clothes were soaked with it. W1 stated that they believed R1 was like that for hours. 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 occured to corroborate W1’s report. No evidence was gathe state’s words, verbatim · CDSS document, Aug 13, 2025 · control 22-AS-20221107172314

Allegation investigated: Lack of supervision resulting in resident engaging in a physical altercation with another resident. Staff yelled at resident. Staff disturbing residents sleep.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Executive Director (ED) Lindsay Schroeder and explained the reason for the visit. The investigation into the allegation, Staff disturbing residents sleep, revealed the following. Resident 1 (R1) moved into the facility on June 10, 2021, and moved out of the facility on August 21, 2021. It was reported that Staff woke up R1 at 6:08 am for a temperature check and at 6:45 am for a shower. No dates were provided as to when these incidents occurred. Witness 1 (W1) reported that R1 told them about the shower at 6:15 am but they were not present at the facility when it took place. A review of records for R1 shows the facility did not perform any temperature checks on R1 that were documented. Staff interviewed reported they don’t do a temperature check unless instructed to by a doctor. Facility progress notes show thatthe state’s words, verbatim · CDSS document, Aug 13, 2025 · control 22-AS-20210823125938

Allegation investigated: Staff did not provide adequate supervision, resulting in resident sustaining a fall

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Executive Director Lindsay Schroeder and explained the reason for the visit. The investigation into the allegation revealed the following. It was reported that Resident 1 (R1) fell June 22, 2025 and was found on the floor by Witness 1 (W1) and Staff 1 (S1). It was reported that a lack of staff led to R1's fall. Only the first name of R1 was provided. A review of records shows 2 residents (Resident 2 and Resident 3) have the same first name as the resident who was reported to have fallen (R1). LPA reviewed the staff schedule and 13 staff members worked on Sunday June 22, 2025. LPA reviewed the facility progress notes of Resident 2 and Resident 3, neither resident suffered a fall in June 2025. Only one fall was reported for June 2025 and it was for a different resident and is oocurred on June 9, 2025. Nothe state’s words, verbatim · CDSS document, Jun 30, 2025 · control 22-AS-20250623133915

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff are not reporting incidents as required Staff are serving expired food to residents

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Adminsitrator Lindsay Schroeder and explained the reason for the visit. The investigation into the allegation, facility staff are not reporting incidents as required revealed the following. It was alleged that the facility did not report an incident with Resident 1 (R1) in which they suffered an unknown injury causing bruising under each eye. LPA interviewed the Administrator and 5 staff members. R1 did suffer an unknown injury. Facility staff reported the incident to the Responsible Party and the Primary Care Physician. The injury was first noted on March 4, 2025, On March 5, 2025 the injury was noted to be around both eyes. R1's nurse practioner (NP) saw R1 on March 7, 2025. R1 was not sent to the hospital. Resident R1 could not be interviewed because they did not respond to the LPA's questions. R1 suthe state’s words, verbatim · CDSS document, Mar 25, 2025 · control 22-AS-20250317100336

Allegation investigated: Facility did not provide requested documents.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Executive Director Lindsay Schroeder and explained the reason for the visit. The investigation revealed the following. LPA interviewed the Executive Director and witness 1. Witness 1 reported that the responsible party requested the facility records for Resident 1 (R1) on December 19, 2024 and the facility acknowledged the request but no records were provided. It was reported that on January 3, 2025 the facility was contacted again about the records request but the facility did not respond and as of January 22, 2025 no records have been received. The Executive Director verified this information and reported the document request was received and the document will be provided by January 28, 2025. Based on the evidence gathered through interviews the preponderance of evidence standard has been met thereforthe state’s words, verbatim · CDSS document, Jan 23, 2025 · control 22-AS-20250113121428

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not prevent a resident from developing a pressure injury while in care

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Executive Director (ED) Lindsay Schroeder and explained the reason for the visit. The investigation revealed the following. It was alleged that the staff did not prevent Resident 1 (R1) from developing a pressure injury while in care. R1 visited the hospital on April 8, 2024 and on April 13, 2024 due to falling. This information was verified through facility documents. On the hospital discharge paperwork for April 8, 2024 there is no mention of a pressure injury. The ED reported they did not receive any hospital discharge paper for the visit on April 13. The the facility notes for R1 do not mention of any pressure injuries. On April 3 the resident notes mention a red lump below the right hip and it will be monitored. On April 19 redness on the right hip area is noted and there is no wound opening. Staffthe state’s words, verbatim · CDSS document, May 8, 2024 · control 22-AS-20240501101419

Allegation investigated: Facility did not provide resident's complete medical records to resident's authorized representative.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Executive Director Lindsay Schroeder and explained the reason for the visit. The investigation revealed the following. It was alleged that the facility did not provide all of the records for Resident 1 to the authorized representative after they were requested. The request for, "the complete chart" was received by the facility on February 21, 2024. On February 28, 2024 the facility emailed to the authorized representative of Resident 1, 147 pages, including the Admission Agreement, Physician's report and resident information. The Administrator verified that the information sent to the authorized representative did not include the Resident's medication administration records and resident notes. Based on the evidence gathered the preponderance of evidence standard has been met, therefore the allegation isthe state’s words, verbatim · CDSS document, Mar 11, 2024 · control 22-AS-20240301164328