The Estate Home 1

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced visit at the facility in conjunction with an investigation of complaint control # 29-AS-20260112144756. During the investigation, LPA observed deficiencies unrelated to the complaint allegations. During the physical plant tour conducted at approximately 11:00 A.M., the LPA observed Resident #1’s (R1’s) bed was equipped with full bed rails. Interviews reflected that upon R1’s admission to the facility, R1 was receiving hospice services; however, hospice services discontinued on 03/17/2023. Review of R1’s Physician’s Report dated September 3, 2025, documents an order for half bed rails for mobility assistance. Furthermore, during the medication audit LPA observed suppositories were not stored in their original packaging, which lacked a pharmacy label identifying the resident to whom the medication was prescribed. Administrator stated that the packaging was discarded. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 14, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(5)(B) · Plan of correction due date: Jan 15, 2026

87608(a)(5)(B) (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on observation, interview, record review, the licensee did not comply with the section cited above. Full bedrail observed on resident's #1 bed and they are not currently on hospice. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 14, 2026

Plan of correction: Admin agreed to remove the full bed rails and replace them with half bed rails to provide mobility assistance. Administrator acknowledged understanding full rails is a form of restraint and not allowed unless under hospice services.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(5) · Plan of correction due date: Jan 15, 2026

Incidental Medical and Dental Care (h) The following requirements shall apply to meds which are centrally stored: (5) Each resident's med... stored in its originally received container. No meds shall be transferred between containers.This requirement is not met as evidenced by: Based on observation, the administrator did not comply as medications were observed without its original labeled container which posed an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 14, 2026

Plan of correction: Administrator agreed to write a statement of understanding on regulation cited above and have in-service training will all staff on this regulation. Statement of understanding due before POC due date. In-service training due 1/22/2026.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 8:45 A.M. LPA was greeted by caregiver, Felicidad “Fely” Cacal who contacted the administrator by telephone. At 9:16 A.M., Administrator, Estrella (Lillian) Alarcon, arrived at the facility, LPA explained the reason for the visit. LPA is conducting the required annual visit for The Estate Home #1 and The Estate Home #2 simultaneously. Entrance interview conducted. Beginning at 10:20 A.M., the LPA, along with Licensee/Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Hardwired combination smoke and carbon monoxide detectors were tested at 10:11 A.M. and were functional at the time of the visit. Fire extinguisher was observed to be fully charged and purchased on 11/06/2025. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 6 (six) total bedrooms for resident use and one (1) designated for staff use. RESTROOMS: The LPA observed six (6) restrooms in the facility. Five (5) are for resident use and one (1) is designated for staff use only. Resident restrooms are clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. Hot water temperature was measured in all resident restrooms. All restrooms measured within the required range. LPA did not check hot water temperature in the staff restroom. Continued on LIC 809-C Continued from LIC 809 COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. Two (2) fireplaces were observed to be adequately screened. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a comfortable temperature of 72 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed. KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. LPA conducted a review of expiration dates on product labels. At 10:29 A.M. hot water was measured at 115.7 degrees Fahrenheit. OUTDOOR SPACE: The backyard is shared between this facility and another related facility. The shared yard has a covered outdoor area equipped with furniture for residents’ use. The facility does have a fountain, but it was observed to be empty at the time of the visit. GARAGE/LAUNDRY ROOM: Adjacent to the staff room is a garage. LPA observed a washer and dryer. Garage remains locked. Garage contains cleaning, incontinence products, and PPE supplies as well as storage. Garage is shared with next door facility. RECORD REVIEW: Between 12:45 P.M. and 1:55 P.M., Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Six (6) resident records reviewed were complete and contained all required documents. Five (5) staff files reviewed were complete and contained all required documents. Continued on LIC 809-C Continued from LIC 809-C EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility’s infection control plan. The facility’s policies and procedures as it pertains to emergency disaster plan are adequate, complete, and updated annually, as required. Emergency drills are conducted quarterly, with the last drill documented on 10/12/2025. MEDICATION REVIEW: At 2:05 P.M. medications for six (6) residents were observed. All residents' prescription medications were observed to be maintained and administered in compliance with regulation at the time of the visit. During today's visit, LPA gathered the following items: Personnel Records (LIC 500), Current certificate of insurance, Resident Rooster (LIC 9020). No citations issued today. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 7, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:00 A.M. LPA met with Licensee/Administrator Estrella (Lillian) Alarcon. Entrance interview conducted. Beginning at 10:20 A.M., the LPA, along with Licensee/Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Hardwired combination smoke and carbon monoxide detectors were tested at 11:00 A.M. and were functional at the time of the visit. Fire extinguishers was observed to be fully charged and purchased on 08/12/2024. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 6 (six) total bedrooms for resident use and 1 (one) designated for staff use. RESTROOMS: The LPA observed 6 (six) restrooms in the facility. 5 (five) are for resident use and 1 (one) is designated for staff use only. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Between 10:35 A.M. and 10:45 A.M. hot water temperature was measured in all resident restrooms. Four (4) restrooms measured within the required range, however restroom next to room # 6, measured 131.3 degrees Fahrenheit. LPA did not check hot water temperature in the staff restroom. Continued on LIC 809-C COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. Two (2) fireplaces were observed to be adequately screened. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a comfortable temperature of 73 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed. KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. LPA conducted a review of expiration dates on product labels. At 10:48 A.M. hot water was measure at 128.4 degrees Fahrenheit. OUTDOOR SPACE: The backyard is shared between this facility and another related facility. The shared yard has a covered outdoor area equipped with furniture for resident use. The facility does have a fountain, but it was observed to be empty at the time of the visit. GARAGE/LAUNDRY ROOM: Adjacent to the staff room is a garage. LPA observed a washer and dryer. Garage remains locked. Garage contains cleaning, incontinence products, and PPE supplies as well as storage. Garage is shared with related facility. RECORD REVIEW: Between 11:15 A.M. and 12:35 P.M., Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Six (6) resident records reviewed were complete and contained all required documents. Three (3) staff files reviewed were complete and contained all required documents. EMERGENCY DISASTER PLAN: Facility was evacuated on 11/06/2024 due to the “Mountain Fire”. During today’s visit, the LPA reviewed the facility’s infection control plan. The facility’s policies and procedures as it pertains to emergency disaster plan are adequate, complete, and updated annually, as required. Emergency drills are conducted monthly, with the last drill documented on 11/02/2024. Continued from LIC 809 Continued from LIC 809-C INTERVIEWS: Throughout the visit, LPA interviewed 2 (two) staff and 1 (one) resident. MEDICATION REVIEW: At 1:15 P.M. medications for six (6) residents were observed. All residents' prescription medications were observed to be maintained and administered in compliance with regulation. During today's visit, LPA gathered the following items: Personnel Records (LIC 500), Current certificate of insurance, Resident Rooster (LIC 9020). Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 18, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 09:45AM. LPA initially met with Facility staff Fely Pudol. Licensee was contacted via telephone and arrived at the facility at 10:28AM. Entrance interview conducted. Beginning at 10:40AM, the LPA, along with Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Hardwired combination smoke and carbon monoxide detectors were tested at 02:32PM and were functional at the time of the visit. Fire extinguishers were observed to be fully charged and purchased on 07/17/2023. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 6 (six) total bedrooms for resident use and 1 (one) designated for staff use. RESTROOMS: The LPA observed 6 (six) restrooms in the facility. 5 (five) are for resident use and 1 (one) is designated for staff use. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in various resident restrooms and measured within the required range. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be adequately screened. KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of Report Continued on LIC 809-C perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. OUTDOOR SPACE: The backyard is shared between this facility and another related facility. The shared yard has a covered outdoor area equipped with furniture for resident use. The facility does have a fountain, but it was observed to be empty at the time of the visit. The garage was observed and contained the laundry area, as well as emergency food supply and water, and storage. RECORD REVIEW: Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 5 (five) resident records reviewed were complete and contained all required documents. 5 (five) staff files reviewed were complete and contained all required documents. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility’s infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually, as required. Emergency drills are conducted monthly, with the last drill documented on 10/06/2023. INTERVIEWS: Throughout the visit, LPA interviewed 2 (two) staff and 1 (one) resident. MEDICATION REVIEW: Medications for 3 (three) residents were observed. All 3 (three) of 3 (three) residents' prescription medications were observed to be maintained and administered in compliance with regulation. During today's visit, LPA gathered the following items: LIC 500 A copy of the facility's liability insurance No deficiencies cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 1, 2023

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.