Sophia's Guest Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hanna Fuller made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Marlene Estebat and discussed the purpose of the visit. The facility is a two-story home, the first floor consists of four resident bedrooms, two bathrooms, living room, dining room, kitchen and attached garage. The second floor has two staff bedrooms and a staff bathroom, no residents reside on the second floor. The facility appears clean, safe and sanitary. All resident bedrooms have the required components and furnishings. LPA observed the kitchen to be clean and free of vermin. LPA observed the knives to be in a locked drawer by the back stove in the staff dining room and made inaccessible. LPA observed the toxins and chemicals to be locked under the sink and made inaccessible. LPA observed a two day perishable and seven day non perishable food supply on hand. LPA observed the emergency food and water supply to be stored in the kitchen. All appliances were found to be operational. LPA observed more toxins and chemicals in the staff dining room in locked cabinets and made inaccessible. LPA observed the resident medications to be locked in a cabinet in the room next to the resident dining area. The resident restrooms are stocked with toilet paper, grab bars, paper towels and non slip mats in the shower. The water was tested between 106.5 and 110.4 degrees Fahrenheit. LPA observed a clean supply of linens in the cupboard by the resident bedrooms. The garage is used for extra facility storage. LPA observed fire extinguishers charged throughout the facility with a service date of July 15, 2026. The backyard is free of debris and obstructions. The fire alarms and carbon monoxide detectors were test by AD and found to be operational. Continue 809C LPA reviewed staff files and 2 of 2 staff do not have TB tests on file. LPA observed resident files and medications and no discrepancies were observed. LPA reviewed resident P&I with AD and no discrepancies were observed. The last fire drill was conducted on June 7, 2026. All staff present are background cleared and associated to the facility. Based on today’s inspection a deficiency is being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with LIC 809D, 859 and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Jul 30, 2026

Allegation investigated: - Licensee does not ensure that staff have required training

On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conduct a complaint investigation. LPA Tea was greeted and granted entry by Administrator (AD) Marlene Borromeo and explained the reason for the visit. The Department received a complaint on Februrary 10, 2026, alleging that the licensee does not ensure that staff obtain required training. During the course of the investigation, LPA Tea conducted interviews, reviewed staff records, and verified training documentation. Administrator (AD) Marlene Borromeo stated that she pays for annual staff training courses each year. She reported that staff complete their training through Assisted Living Education, a California Department of Social Services (DSS) approved Continuing Education Unit (CEU) vendor. AD Borromeo provided documentation showing proof of monthly payments toward the annual training program. (Complaint investigation continued on LIC9099C) Unfounded AD Borromeo stated that staff complete required annual training, which is monitored and reviewed during annual licensing inspections. She further reported that all staff will complete their annual training requirements by the next annual inspection, consistent with prior inspection reviews. When asked if there were any forged, altered, or duplicated training certificates or records, AD Borromeo denied any falsification of records and advised that Licensing may contact the training vendor for verification. LPA interviewed two staff present at the facility during the visit. Both staff were recently hired and had not yet reached their one-year employment anniversary. Review of Regional Center regulations confirms that Direct Support Professional (DSP) training must be completed within one (1) year of hire. Therefore, the staff were still within the allowable time frame for completion. Both staff reported receiving on-the-job training and annual training. LPA reviewed personnel files and verified documentation of completed medication training and required annual training components. AD Borromeo explained that due to staff turnover, she prioritizes critical trainings, including medication administration and annual mandatory trainings, upon hire. LPA also reviewed training records for senior staff and verified completion of required annual DSP training hours. At the time of the complaint, all staff training reviewed was current and valid. LPA further verified training documentation directly with the training vendor. LPA spoke with Taylor Dalhquist, Vice President of Operations, who confirmed that the training dates for the staff in question were valid and properly certified. She also confirmed that the Administrator maintains an annual training subscription, billed monthly, to ensure staff remain compliant with Licensing and Regional Center training requirements. Based on interviews conducted, record reviews, and third-party verification of training documentation, there is insufficient evidence to support the allegation that the licensee does not ensure staff have required training. Therefore the allegation mention above has been determined as UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. No deficiencies cited at this time and an exit interview was conducted with Administrator (AD) Marlene Borromeo. A copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, Feb 17, 2026 · control 22-AS-20260210124049

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by Administrator (AD) Marlene Estebat and explained the reason for the visit. The facility is licensed for three ambulatory residents, three non-ambulatory residents, which one maybe bedridden with a hospice waiver for two. Currently there are four residents, and no one is on hospice. LPA Tea reviewed four resident files and four staff files. Resident files and staff files contained all the required documentation. Just one minor issue, upon review of records residents only have Regional Center Orange County (RCOC) Admission Agreements. LPA explained to AD Estebat that residents need to have a separate admission agreement that meets Title 22 requirements on file for residents. Also, the facility has RCOC’s medical consent forms and needs to have the Department’s medical consent forms. The facility is up to date with required quarterly emergency disaster drills, which were last conducted on June 19, 2025. AD Estebat administrator certificate has an expiration date of February 14, 2025. LPA Tea along with AD Estebat toured the facility. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a two-story home, the first floor consists of four resident bedrooms, two bathrooms, living room, dining room, kitchen and attached garage. The second floor is only for staff where live in care staff resides, no residents reside on the second floor. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and showers were free of mold/mildew. The water temperature measured around 125 Fahrenheit degrees. Facility tried to adjust the (Annual Inspection continued on LIC809C) water temperature and has placed “Caution Hot Water” signs by the sinks. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards; doorways were free of obstructions. First aid kit had all the required elements including dressing, bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked and inaccessible to residents in a kitchen drawer in the staff quarters. LPAs also observed toxin substances secured underneath the kitchen sink and cabinets in the staff quarters. The fire extinguishers are fully charged throughout the facility. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating underneath a shaded patio area in the backyard. There is a barbecue grill. There are two exit gates that are self-latching and operational on both sides of the house. LPA observed PPE supplies, emergency food and water stored in the kitchen. Facility provides activities based on their personal choice. Residents play games, color and do art activities. They also go on outings. Residents like to go on outings like the park, going to the beach, shopping and getting burgers at Carl’s Jr. At the time of the visit, LPA observed residents coloring and lounging in the living room watching tv. LPA reviewed medication storage and administration. Medications are stored in a locked cabinet by the kitchen area. Medications are being administered per physician order. P&I funds were accounted for and there were no discrepancies. LPAs interviewed residents regarding their quality of care and spoke to staff present regarding care provided. Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with Administrator Marlene Estebat and a copy of this report LIC809, along with the 809-C, LIC858, and LIC859, LIC9012 TV were read and provided to the facility.the state’s words, verbatim · CDSS document, Aug 5, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On September 18, 2024, at 2:00pm, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Administrator (AD) Marlene Estebat. The facility is licensed to operate for three (3) ambulatory residents and three (3) nonambulatory residents of which one (1) may be bedridden and have a hospice waiver for two (2) residents. The facility is a two story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, two (2) Staff Bedroom, four (4) bathrooms, living area, dining area, staff office room, resident kitchen, staff kitchen, and an attached two car garage. LPA Kim toured inside and outside of the physical plant with AD Estebat. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, Staff Room 1, and Staff Room 2. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 113.7 degrees F to 115.3 degrees F. A comfortable temperature of 77 degrees F was maintained in the facility. LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The two kitchens were inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, emergency water, and emergency supplies were stored in the kitchen. Evaluation Report Continues on LIC 809-C During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-760-4101) remains available. First Aid kit had all the necessary elements. The facility has three (3) fire extinguishers that were fully charged, mounted in the kitchen near the entrance, resident hallway, and the staff kitchen that were all serviced on August 20, 2024. LPA Kim conducted an audit of two (2) resident files (R1-R2), eight (8) staff files (S1-S8), and medication and medication administration review were all in order and complete. LPA Kim conducted two (2) staff interview and two (2) resident interviews. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to Administrator Marlene Estebat.the state’s words, verbatim · CDSS document, Sep 18, 2024