Inspection Reports for
Estancia Del Sol

CA, 92881

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Deficiencies (last 5 years)

Deficiencies (over 5 years) 2.2 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

45% better than California average
California average: 4 deficiencies/year

Deficiencies per year

8 6 4 2 0
2021
2022
2023
2024
2025

Occupancy

Latest occupancy rate 87% occupied

Based on a September 2025 inspection.

Occupancy rate over time

64% 72% 80% 88% 96% 104% Sep 2021 Sep 2022 Nov 2023 Apr 2025 Sep 2025

Inspection Report

Annual Inspection
Census: 118 Capacity: 135 Deficiencies: 0 Date: Sep 11, 2025

Visit Reason
The visit was an unannounced required comprehensive annual inspection conducted by Licensing Program Analyst Mary Rico to evaluate the facility's compliance with licensing requirements.

Findings
The facility was found to be operating within its licensed capacity and in good repair with no obstructions or safety hazards. Resident bedrooms and common areas were properly equipped and maintained. Food supply and care staffing were sufficient. Record reviews showed compliance with admission agreements, physician reports, medication, hospice, and staff certifications. No deficiencies were cited during this inspection.

Report Facts
Resident files reviewed: 10 Resident medications reviewed: 10 Hospice files reviewed: 5 Staff files reviewed: 10

Employees mentioned
NameTitleContext
Lisa HuntAdministratorMet with Licensing Program Analyst during inspection and discussed report
Mary RicoLicensing Program AnalystConducted the unannounced annual inspection

Inspection Report

Annual Inspection
Census: 118 Capacity: 135 Deficiencies: 0 Date: Sep 11, 2025

Visit Reason
The visit was an unannounced required comprehensive annual inspection conducted by Licensing Program Analyst Mary Rico to evaluate the facility's compliance with licensing requirements.

Findings
The facility was found to be operating within its approved capacity and in safe, clean, and good repair conditions. No deficiencies were cited during the inspection across physical plant, food service, care and supervision, and record review areas.

Report Facts
Resident files reviewed: 10 Resident medications reviewed: 10 Hospice files reviewed: 5 Staff files reviewed: 10

Employees mentioned
NameTitleContext
Lisa HuntAdministratorMet with Licensing Program Analyst during inspection and involved in facility operations
Mary RicoLicensing Program AnalystConducted the unannounced annual inspection visit
Efren MalagonLicensing Program ManagerNamed as Licensing Program Manager on the report

Inspection Report

Complaint Investigation
Census: 118 Capacity: 135 Deficiencies: 0 Date: May 19, 2025

Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2024-03-04 regarding improper cleaning and sanitizing of dishes and utensils, failure to follow hand hygiene procedures, and failure to treat residents with dignity and respect.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included improper cleaning and sanitizing of dishes and utensils, failure to follow hand hygiene procedures, and failure to treat residents with dignity and respect. Evidence did not support these allegations.
Findings
The investigation included resident and staff interviews, facility tour, and document review. All three allegations were found to be unsubstantiated based on evidence, with no deficiencies cited during the visit.

Report Facts
Staff interviewed: 6 Residents interviewed: 8 Allegations investigated: 3

Employees mentioned
NameTitleContext
Lisa HuntAdministratorMet during investigation and named in report
Mary RicoLicensing Program AnalystConducted the complaint investigation
Antionette DavisLicensing Program AnalystAssisted in conducting the complaint investigation
Efren MalagonLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Complaint Investigation
Census: 118 Capacity: 135 Deficiencies: 0 Date: May 19, 2025

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-03-04 regarding staff cleaning and sanitizing dishes, hand hygiene procedures, and treatment of residents with dignity and respect.

Complaint Details
The complaint involved three allegations: improper cleaning and sanitizing of dishes and utensils, failure to follow hand hygiene procedures, and failure to treat residents with dignity and respect. The investigation found all allegations unsubstantiated.
Findings
The investigation included resident and staff interviews, facility tour, and document review. All three allegations were found to be unsubstantiated based on evidence, with staff properly cleaning dishes, following hygiene procedures, and treating residents with dignity and respect. No deficiencies were cited during the visit.

Report Facts
Capacity: 135 Census: 118 Staff interviewed: 6 Residents interviewed: 8

Employees mentioned
NameTitleContext
Mary RicoLicensing EvaluatorConducted the complaint investigation
Lisa HuntAdministratorFacility administrator met during the investigation
Antionette DavisLicensing Program AnalystAssisted in conducting the unannounced visit
Efren MalagonSupervisorSupervisor overseeing the investigation

Inspection Report

Complaint Investigation
Census: 124 Capacity: 135 Deficiencies: 1 Date: Apr 23, 2025

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff did not dispense medication as prescribed resulting in hospitalization, and that staff did not address a change in a resident's condition.

Complaint Details
The complaint investigation was triggered by allegations that facility staff did not dispense medication as prescribed resulting in hospitalization and failed to address a resident's change in condition. The medication error allegation was unsubstantiated, but the failure to observe change in condition was substantiated with one deficiency cited.
Findings
The investigation substantiated that facility staff failed to observe a resident's change in condition, resulting in a deficiency citation. However, the allegation that medication was incorrectly dispensed causing a stroke was unsubstantiated due to lack of evidence. One deficiency was cited related to failure to observe resident condition changes.

Deficiencies (1)
Failure to observe a change in condition for Resident #1, posing an immediate health, safety, or personal rights risk.
Report Facts
Facility capacity: 135 Census: 124 Deficiencies cited: 1 Medication dosage error multiplier: 3 Time to stroke after medication error: 36 Plan of Correction due date: Apr 24, 2025

Employees mentioned
NameTitleContext
Mary RicoLicensing Program AnalystConducted the complaint investigation and delivered findings
Lisa HuntAdministratorFacility administrator met during investigation and exit interview
Efren MalagonLicensing Program ManagerOversaw licensing program and signed report

Inspection Report

Complaint Investigation
Census: 124 Capacity: 135 Deficiencies: 1 Date: Apr 23, 2025

Visit Reason
An unannounced case management visit was conducted to deliver findings related to a complaint control 56-AS-20231107145012 concerning a medication error.

Complaint Details
The visit was complaint-related, investigating a medication error where staff administered incorrect medication dosage to resident R1. The deficiency was substantiated and cited as Type A.
Findings
The investigation found that on 2023-06-28, staff member S2 administered resident R1's medication incorrectly by increasing the dosage to three times the prescribed amount instead of lowering it to half. One Type A deficiency was cited due to this medication error posing an immediate risk to health and safety.

Deficiencies (1)
S2 provided R1 the wrong medication dosage, increasing it to three times the prescribed amount instead of lowering it to half, posing an immediate health, safety, or personal rights risk.
Report Facts
Deficiencies cited: 1 Medication dosage error multiplier: 3 Plan of Correction due date: Apr 23, 2025

Employees mentioned
NameTitleContext
Lisa HuntAdministratorMet with Licensing Program Analyst during inspection and named in report
Mary RicoLicensing Program AnalystConducted the unannounced case management visit and authored the report

Inspection Report

Complaint Investigation
Census: 124 Capacity: 135 Deficiencies: 1 Date: Apr 23, 2025

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff did not dispense medication as prescribed resulting in hospitalization and failed to address a resident's change in condition.

Complaint Details
The complaint investigation was initiated due to allegations that facility staff did not dispense medication as prescribed resulting in hospitalization and failed to address a resident's change in condition. The failure to observe the resident's change in condition was substantiated, while the medication error allegation was unsubstantiated.
Findings
The investigation substantiated that facility staff failed to observe Resident #1's change in condition, which led to a deficiency citation. However, the allegation that medication was incorrectly dispensed causing the resident's stroke was unsubstantiated due to lack of evidence linking the stroke to medication error.

Deficiencies (1)
Facility staff failed to observe a change in condition for Resident #1, posing an immediate health, safety, or personal rights risk to persons in care.
Report Facts
Capacity: 135 Census: 124 Deficiencies cited: 1 Plan of Correction due date: Apr 24, 2025

Inspection Report

Annual Inspection
Census: 119 Capacity: 135 Deficiencies: 0 Date: Nov 8, 2024

Visit Reason
The visit was an unannounced required comprehensive annual inspection conducted by the Licensing Program Analyst Mary Rico to evaluate the facility's compliance with regulations.

Findings
The facility was found to be operating within approved capacity and in good repair with no obstructions or safety hazards. Resident rooms and common areas were adequately furnished and maintained. Food service and care staffing were sufficient. No deficiencies were cited during the inspection.

Report Facts
Resident files reviewed: 6 Resident medications reviewed: 6 Hospice files reviewed: 6 Staff files reviewed: 6

Employees mentioned
NameTitleContext
Lisa HuntAdministratorMet with Licensing Program Analyst during inspection and named in report
Mary RicoLicensing Program AnalystConducted the unannounced annual inspection
Efren MalagonLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Annual Inspection
Census: 119 Capacity: 135 Deficiencies: 0 Date: Nov 8, 2024

Visit Reason
The visit was conducted as a required comprehensive annual inspection to evaluate the facility's compliance with regulations.

Findings
The facility was found to be operating within its licensed capacity, clean, well-maintained, and safe for residents. No deficiencies were cited during the inspection.

Report Facts
Resident files reviewed: 6 Resident medications reviewed: 6 Hospice files reviewed: 6 Staff files reviewed: 6

Employees mentioned
NameTitleContext
Lisa HuntAdministratorMet with Licensing Program Analyst during inspection and accompanied inspection
Mary RicoLicensing Program AnalystConducted the unannounced annual inspection visit
Efren MalagonSupervisorSupervisor overseeing the inspection

Inspection Report

Annual Inspection
Census: 125 Capacity: 135 Deficiencies: 1 Date: Nov 13, 2023

Visit Reason
The visit was an unannounced Health and Safety check conducted simultaneously with the annual inspection to observe the facility's conditions including food supply, medications, physical plant, and residents in care.

Findings
One deficiency was cited during the annual inspection for not covering a tray of Jello in the refrigerator, resulting in a type B deficiency.

Deficiencies (1)
Tray of Jello uncovered in the refrigerator
Report Facts
Deficiencies cited: 1

Employees mentioned
NameTitleContext
Ryan GardnerLicensing Program AnalystConducted the Health and Safety check and annual inspection
Lisa HuntAdministratorFacility administrator met during the inspection
Efren MalagonLicensing Program ManagerNamed in the report header

Inspection Report

Annual Inspection
Census: 125 Capacity: 135 Deficiencies: 1 Date: Nov 13, 2023

Visit Reason
The visit was an unannounced required comprehensive annual inspection conducted by the Licensing Program Analyst Ryan Gardner to evaluate compliance with regulations at the Residential Care Facility for the Elderly.

Findings
The facility was found to be operating safely and in good repair with sufficient staffing and proper record keeping. One deficiency was cited for a food service violation where uncovered Jello was found in the refrigerator, posing a potential health risk.

Deficiencies (1)
Uncovered Jello containers in the refrigerator, violating food service requirements for storing perishable foods in covered containers.
Report Facts
Residents files reviewed: 8 Staff files reviewed: 8 Deficiencies cited: 1 Water temperature: 114.6

Employees mentioned
NameTitleContext
Lisa HuntAdministratorMet with Licensing Program Analyst during inspection and received report
Ryan GardnerLicensing Program AnalystConducted the inspection and authored the report
Efren MalagonLicensing Program ManagerSupervisor overseeing the inspection

Inspection Report

Annual Inspection
Census: 125 Capacity: 135 Deficiencies: 1 Date: Nov 13, 2023

Visit Reason
The visit was an unannounced Health and Safety check conducted at the same time as the annual inspection to observe the facility's overall condition including food supply, medications, physical plant, and residents in care.

Findings
One deficiency was cited during the annual inspection for a Type B violation related to uncovered Jello found in the refrigerator during the kitchen tour.

Deficiencies (1)
Tray of Jello uncovered in the refrigerator
Report Facts
Deficiencies cited: 1

Employees mentioned
NameTitleContext
Lisa HuntAdministratorMet with Licensing Program Analyst during inspection and was provided a copy of the report
Ryan GardnerLicensing Program AnalystConducted the unannounced Health and Safety check and annual inspection
Efren MalagonSupervisorSupervisor overseeing the inspection

Inspection Report

Annual Inspection
Census: 125 Capacity: 135 Deficiencies: 1 Date: Nov 13, 2023

Visit Reason
The visit was an unannounced required comprehensive annual inspection of the Residential Care Facility for the Elderly (RCFE) to assess compliance with licensing regulations.

Findings
The facility was found to be operating safely and in good repair with sufficient staffing and proper record keeping. One deficiency was cited for a food service violation where uncovered Jello was found in the refrigerator, posing a potential health and safety risk.

Deficiencies (1)
Uncovered Jello containers in the refrigerator, violating food service requirements for storing perishable foods in covered containers.
Report Facts
Residents files reviewed: 8 Staff files reviewed: 8 Deficiencies cited: 1

Employees mentioned
NameTitleContext
Lisa HuntAdministratorMet with Licensing Program Analyst during inspection and received report
Ryan GardnerLicensing Program AnalystConducted the inspection and authored the report
Efren MalagonSupervisorSupervisor overseeing the licensing evaluation

Inspection Report

Complaint Investigation
Census: 125 Capacity: 135 Deficiencies: 0 Date: Jun 20, 2023

Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that staff did not properly assess residents' needs.

Complaint Details
The complaint alleged that staff did not properly assess residents' needs. The allegation was found unsubstantiated after investigation, meaning there was not a preponderance of evidence to prove the violation occurred.
Findings
The investigation found the allegation unsubstantiated based on observations and interviews. The report details an incident involving a deceased resident and staff response, concluding there was insufficient evidence to prove the alleged violation.

Report Facts
Facility capacity: 135 Census: 125

Employees mentioned
NameTitleContext
Lisa HuntExecutive DirectorMet with Licensing Program Analyst during investigation and named in report findings
Javina GeorgeLicensing Program AnalystConducted the complaint investigation visit
Joel EsquivelLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Complaint Investigation
Census: 125 Capacity: 135 Deficiencies: 2 Date: Jun 20, 2023

Visit Reason
An unannounced case management deficiencies visit was conducted in correlation to complaint control number 18-AS-20200513115313 to investigate reported deficiencies.

Complaint Details
Visit was triggered by complaint control number 18-AS-20200513115313. The complaint was substantiated as deficiencies were cited related to neglect and failure to report.
Findings
The facility failed to meet resident needs due to staff connecting a resident to the wrong respiratory machine, and failed to report the incident as required. Staff received counseling and the facility provided training on the difference between oxygen and nebulizer treatments.

Deficiencies (2)
Neglect/lack of care and supervision - staff failed to meet resident's needs by connecting Resident #1 to the wrong respiratory machine.
Failure to follow reporting requirements - the facility did not report the incident of Resident #1 not being hooked up to their oxygen machine as required.
Report Facts
Capacity: 135 Census: 125 Plan of Correction Due Date: Jul 4, 2023

Employees mentioned
NameTitleContext
Lisa HuntExecutive DirectorFacility administrator present during the inspection and named in the exit interview.
Javina GeorgeLicensing Program AnalystConducted the inspection and authored the report.
Joel EsquivelLicensing Program ManagerSupervisor overseeing the inspection.

Inspection Report

Complaint Investigation
Census: 125 Capacity: 135 Deficiencies: 0 Date: Jun 20, 2023

Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not properly assess residents' needs.

Complaint Details
The complaint alleged that staff did not properly assess residents' needs, specifically citing an incident where a resident was found deceased and staff responses were questioned. The allegation was found unsubstantiated.
Findings
The investigation found the allegation to be unsubstantiated based on observations and interviews, with no preponderance of evidence proving the alleged violation occurred.

Report Facts
Complaint Control Number: 18 Complaint Control Number Suffix: 20200804111522

Employees mentioned
NameTitleContext
Javina GeorgeLicensing Program AnalystConducted the complaint investigation and made the unannounced visit
Lisa HuntExecutive DirectorMet with the Licensing Program Analyst during the investigation and provided information
Nancy HalleckAdministratorFacility administrator mentioned in relation to the internal investigation

Inspection Report

Complaint Investigation
Census: 125 Capacity: 135 Deficiencies: 2 Date: Jun 20, 2023

Visit Reason
An unannounced case management deficiencies visit was conducted in correlation to complaint control number 18-AS-20200513115313 to investigate alleged neglect and failure to meet resident needs.

Complaint Details
The visit was triggered by complaint control number 18-AS-20200513115313. The complaint was substantiated as deficiencies were cited related to neglect and failure to report an incident.
Findings
The facility failed to provide proper care and supervision to Resident #1, who was hooked up to the wrong respiratory machine, and failed to report the incident as required. Staff received counseling and training was provided to all staff on the difference between oxygen and nebulizer treatments.

Deficiencies (2)
Neglect/lack of care and supervision - staff failed to meet resident's needs by hooking Resident #1 to the wrong respiratory machine.
Failure to report the incident of Resident #1 not being hooked up to their oxygen machine as required.
Report Facts
Census: 125 Total Capacity: 135 Plan of Correction Due Date: Jul 4, 2023

Employees mentioned
NameTitleContext
Lisa HuntExecutive DirectorFacility representative met during inspection and recipient of report and appeal rights
Javina GeorgeLicensing Program AnalystLicensing evaluator who conducted the inspection
Joel EsquivelSupervisorSupervisor overseeing the licensing evaluation

Inspection Report

Annual Inspection
Census: 126 Capacity: 135 Deficiencies: 0 Date: Sep 23, 2022

Visit Reason
The visit was an unannounced required annual inspection with an emphasis on infection control due to the COVID-19 pandemic.

Findings
The facility was found to be in compliance with no deficiencies cited. The facility has a comprehensive COVID-19 infection control plan, adequate PPE supplies, and follows Community Care Licensing Division guidelines.

Report Facts
Staff present: 22 PPE supply duration: 30

Employees mentioned
NameTitleContext
Ryan GardnerLicensing Program AnalystConducted the inspection and authored the report
Morgan CadmusRegional Director of OperationsFacility representative met during inspection and exit interview
Karen ClemonsLicensing Program ManagerNamed in the report as Licensing Program Manager

Inspection Report

Annual Inspection
Census: 126 Capacity: 135 Deficiencies: 0 Date: Sep 23, 2022

Visit Reason
The visit was conducted as a required annual inspection with an emphasis on infection control due to the COVID-19 pandemic.

Findings
No deficiencies were cited during the inspection. The facility demonstrated compliance with COVID-19 infection control best practices, including PPE supply management, visitor screening, and resident safety measures.

Report Facts
Staff present: 22 PPE supply duration: 30

Employees mentioned
NameTitleContext
Morgan CadmusRegional Director of OperationsMet with Licensing Program Analyst during inspection and received the report
Ryan GardnerLicensing Program AnalystConducted the inspection and authored the report
Karen ClemonsSupervisorSupervisor overseeing the inspection

Inspection Report

Complaint Investigation
Census: 107 Capacity: 135 Deficiencies: 0 Date: Mar 8, 2022

Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff were rough with residents, yelled at residents, and pushed residents.

Complaint Details
The complaint investigation was unsubstantiated based on interviews and information gathered. Allegations included staff being rough with residents, yelling at residents, and pushing residents, all of which were denied by staff and residents.
Findings
The investigation included interviews with staff and residents, and found no preponderance of evidence to substantiate the allegations. Staff and residents denied the allegations, and the facility has a zero-tolerance policy for abuse and neglect. The allegations were determined to be unsubstantiated.

Report Facts
Capacity: 135 Census: 107

Employees mentioned
NameTitleContext
Jennifer SeminLicensing Program AnalystConducted the complaint investigation
Lisa HuntAdministratorFacility administrator met during investigation

Inspection Report

Complaint Investigation
Census: 107 Capacity: 135 Deficiencies: 0 Date: Mar 8, 2022

Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2022-03-02 regarding staff behavior towards residents, including rough handling, yelling, and pushing.

Complaint Details
The complaint investigation was unsubstantiated as there was no preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation included interviews with staff and residents. No evidence was found to substantiate the allegations; staff and residents denied or were unable to corroborate the claims. The allegations were determined to be unsubstantiated.

Report Facts
Capacity: 135 Census: 107

Employees mentioned
NameTitleContext
Jennifer SeminLicensing Program AnalystConducted the complaint investigation and authored the report
Lisa HuntAdministratorFacility administrator met during the investigation
Efren MalagonLicensing Program ManagerNamed as Licensing Program Manager on the report

Inspection Report

Annual Inspection
Census: 103 Capacity: 135 Deficiencies: 0 Date: Sep 9, 2021

Visit Reason
The visit was an unannounced annual inspection limited to infection control, including a COVID-19 Risk Assessment Screening.

Findings
The facility was found to be successfully incorporating its COVID-19 Mitigation Plan with adequate hand sanitizer availability, stocked bathrooms, multiple infection control postings, and properly stored PPE supplies. Staff fit testing for N95 masks was ongoing with many already completed.

Employees mentioned
NameTitleContext
Lisa HuntAdministratorMet with Licensing Program Analyst during inspection and discussed infection control practices.
Jennifer SeminLicensing Program AnalystConducted the inspection and COVID-19 Risk Assessment Screening.
Karen ClemonsLicensing Program ManagerNamed in report header.

Inspection Report

Annual Inspection
Census: 103 Capacity: 135 Deficiencies: 0 Date: Sep 9, 2021

Visit Reason
The inspection visit was an unannounced annual inspection limited to infection control, conducted after a COVID-19 Risk Assessment Screening.

Findings
The facility was found to be successfully incorporating its COVID-19 Mitigation Plan, with adequate hand sanitizer availability, stocked bathrooms, proper PPE supplies, and updated emergency contact information. Staff fit testing for N95 masks was ongoing with some staff already fit tested and others scheduled.

Report Facts
Staff fit testing scheduled date: Sep 14, 2021

Employees mentioned
NameTitleContext
Jennifer SeminLicensing Program AnalystConducted the inspection and met with the administrator
Lisa HuntAdministratorFacility administrator met during inspection and discussed infection control practices
Karen ClemonsSupervisorSupervisor named in the report

Report

June 20, 2023

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