SERRA SOL

Official classification

Type B

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on interviews and record review, licensee did not find a solution necessary to prevent R1’s from sustaining multiple fall and a fall risk plan was not implemented, which posed an potential Health, Safety, and/or Personal Rights risk to persons in care.

Official plan of correction

Executive Director, Christine Greenway, stated that all care staff will be trained to meet all residents’ fall needs, and will submit an Acknowledgement of Understanding of the said deficiency. The above statement and training records will be submitted to LPA via email by POC due date.

Deadline recorded: May 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by... R1 left the facility unattended on May 2, 2026, R1 is not allowed to leave the facility unassisted, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee agrees to conduct an in-service training for all staff members on CCR 87464 and provide a copy of the sign-in sheet for all staff in attendance. Licensee agrees to provide an outline of topics covered in the in-service, including the duration of the in-service training and a list of all participants. Proof of correction to be sent to the LPA.

Deadline recorded: May 14, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first... This requirement is not being met as evidenced by, R1's last care plan (reappraisal) was completed on January 3, 2023, which is 12 months and 2 weeks after the previous care plan (reappraisal) which poses a potential, health and safety risk to the Resident (R1).

Official plan of correction

Licensee agrees to have staff responsible for completing care plans (reappraisals) trained on CCR 87463 and to submit proof of training to LPA by the POC due date.

Deadline recorded: Oct 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(e)(5)

Regulation authority

CCR

What the official deficiency says

Care Of Persons With Dementia 87705(e)(5) Facility staff shall ensure the continued safety of residents if they wander away from the facility... This requirement is not met as evidence by: 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.

Official plan of correction

Licensee agrees to train all staff on elopement prevention training and to provide proof of training to LPA by the POC due date.

Deadline recorded: Aug 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. (D)Any incident which threatens the welfare, safety or health of any resident, This requirement was not met as evidenced by, staff reported R1 had an unknown that was not reported to the Agency, this poses a potential health, safety and/or personal rights risks to residents in care.

Official plan of correction

Licensee agrees to train staff on CCR 87211 reporting requirements and to submit proof of training to LPA >

Deadline recorded: Apr 1, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

...All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not being met as evidenced by; LPA observed 12 cans of expired soup stored in the kitchen food storage area. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee agrees to check all of stored food and to dispose of all expired food in the kitchen by the POC due date.

Deadline recorded: Apr 1, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.269(a)(21)

Regulation authority

HSC

What the official deficiency says

To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. This requirement was not met as evidenced by, Based on interviews the facility did not provide the requested documents within two business days, once requested. This poses a personal rights risk to residents.

Official plan of correction

Licensee agrees to provide the records requested by January 28, 2025 and the Executive Director will sign a statement of understanding for the regulation HSC 1569.269, proof of completion to be submitted to the LPA by January 31, 2025.

Deadline recorded: Jan 31, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 2 out of 5 resident files (Resident 1 and Resident 2) which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/03/2024 Plan of Correction Licensee agrees to have new updated medical assessments completed for Resident 1 and Resident 2 and to submit the completed medical assessments to the LPA by the POC due date.

Official classification

Type B

Official code

1569.269(a)(21)

Regulation authority

HSC

What the official deficiency says

(21)To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. This requirement was not met as evidenced by, the facility did not provide Resident 1's medication administration records and resident notes. This poses a potential health and safety risk to residents.

Official plan of correction

Licensee agrees to have the Administrator provide a statement of understanding for the regulation HSC 1569.269 and to provide Resident 1's authorized representative their medication administration records and resident notes. Administrator to provide POC to LPA by POC due date.

Deadline recorded: Mar 18, 2024. A deadline is not proof that correction was completed.