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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701678
Report Date: 07/20/2026
Date Signed: 07/20/2026 04:54:10 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/15/2026 and conducted by Evaluator Shakaricka Hughes
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260715140549
FACILITY NAME:ESTELA HOME CAREFACILITY NUMBER:
342701678
ADMINISTRATOR:RUFAEL, MULUFACILITY TYPE:
740
ADDRESS:1 NITEL CTTELEPHONE:
(408) 329-8282
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 4DATE:
07/20/2026
UNANNOUNCEDTIME BEGAN:
03:37 PM
MET WITH:Administrator: Mulu RufaelTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Licensee admitted/retained a resident who is bedridden without bedridden fire clearance.
INVESTIGATION FINDINGS:
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On 07/20/2026, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with the facility administrator Mulu Rufael and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegation above. The current census is 4.

Allegation: Licensee admitted/retained a resident who is bedridden without bedridden fire clearance.
It was alleged that the licensee admitted and retained a resident who is bedridden without a bedridden fire clearance. This investigation consisted of interviews with facility staff, residents, and records review. On 07/20/2026, LPA Hughes conducted a visit to the facility and interviewed the facility administrator, who stated they became concerned that Resident (R1) was not repositioning in bed independently and contacted the Sacramento Metro Fire District for guidance. The administrator further stated they observed R1 occasionally reposition themselves in bed and, therefore believed R1 was bedbound.
Continuation 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20260715140549
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ESTELA HOME CARE
FACILITY NUMBER: 342701678
VISIT DATE: 07/20/2026
NARRATIVE
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Although the administrator believed that R1 was bedbound rather than bedridden, the administrator acknowledged that R1 required ongoing assistance with repositioning and was unable to independently leave or reposition in bed. LPA interviewed R1, who stated they are unable to reposition themselves in bed without assistance due to pain and require staff assistance to transfer into their wheelchair. LPA reviewed the facility’s STD 850 Fire Inspection Report, which confirmed the facility does not have an approved bedridden fire clearance. LPA also reviewed R1’s LIC 602 Physician’s Report, which identified R1 as non-ambulatory. This was observed not in compliance with Title 22 regulation 87202(a)(2) as the facility did not ensure an approved fire clearance was obtained prior to admitting and retaining a bedridden resident.


As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility.
 
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20260715140549
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ESTELA HOME CARE
FACILITY NUMBER: 342701678
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2026
Section Cited
CCR
87202(a)(2)
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87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved... or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance…(2) Bedridden persons
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The licensee agrees to have resident (R1) re-evaluated by a licensed physician, to determine the resident's current ambulatory status and obtain an updated LIC 602 Physicians Report. The licensee wil also submit a request for a fire inspection to obtain the appropriate..
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This requirement was not met as evidenced by:
Based on interviews, and records review, the licensee did not ensure that the facility obtained an approved fire clearance prior to accepting and retaining resident (R1) who was determined to be bedridden.
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fire clearance based on the resident's ambulatory status and will provide the request to licensing for approval. The licensee will send the residents updated LIC 602 Physicians Report and request for a new fire clearance to LPM Arielle.Pascua@dss.ca.gov.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3