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Inspection visit

Complaint

SERRA HIGHLANDS SENIOR LIVINGLicense 4156011272 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

Based on training records reviewed, there are 7 med-techs in total and both S1 and S2 did not complete their 16 hours of initial training prior to administering medications to residents in care. In addition, based on training records reviewed, LPA did not observe med-techs receiving their annual on-the-job training in relation to policies and procedures regarding medications on top of their initial required training to be able to administer medication to residents in care. The facility was unable to provide me any documentation to show med-techs are receiving their annual on-the-job training. Based on information collected and files reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Resident Services Director and a copy is provided with appeal rights. LPA conducted a medication count for R1’s Levothyroxine. LPA observed the amount of medications in the bottle corresponded with the start date of the medication listed on the centrally stored medication record. In addition, according to staff interviews, R1 does not take alendronate. LPA confirmed that alendronate is not on the R1’s prescribed medication list and MAR. Based on documents reviewed, information collected, observations, and interviews conducted, the department has determined that although the above allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is UNSUBSTANTIATED.

Citations

3 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 1569.69(a)(1)Type A

    §1569.69 Employees assisting residents with self-administration of medication; training requirements: (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 16 hours of initial training... This training shall consist of eight hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medication which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by: Based on training records reviewed, S1 and S2 did not have their initial 16 hours of training documented prior to administering medication to residents in care which poses an immediate health and safety risk to residents in care.

  • 87411(c)(3)(D)Type A

    87411 Personnel Requirements - General: (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (3) The training shall include, but not be limited to, the following:(D) Policies and procedures regarding medications, including the knowledge in Section 87411(d)(4). This requirement is not met as evidenced by: The facility was unable to provide LPA documentation to show med-techs have been receiving their annual on-the-job training. LPA did not observe any annual trainings in med-techs files during file review.

  • 87412(c)Type B

    Document required staff training and orientation

    87412 Personnel Records: (c) Licensees shall maintain in the personnel records verification of required staff training and orientation.This requirement is not met as evidenced by: Based on 7 personnel records reviewed, LPA did not observe any staff training records in the files. In addition, facility was unable to provide it to LPA during the complaint visit on 3/5/26 which poses a potential health and safety risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the March 13, 2026 inspection of SERRA HIGHLANDS SENIOR LIVING?

This was a complaint inspection of SERRA HIGHLANDS SENIOR LIVING on March 13, 2026. 2 citations were issued: 2 Type A (serious).

Were any citations issued to SERRA HIGHLANDS SENIOR LIVING on March 13, 2026?

Yes, 2 citations were issued (2 Type A, 0 Type B). The first citation was for: "§1569.69 Employees assisting residents with self-administration of medication; training requirements: (1) In facilities..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.