216890070-4-28-2026-21-AS-CCOO-DTKVEQ-20260428162244

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216890070
Report Date: 04/28/2026
Date Signed: 04/28/2026 04:23:01 PM

Document Has Been Signed on 04/28/2026 04:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	HACIENDA HOME		FACILITY NUMBER:	216890070
ADMINISTRATOR/ DIRECTOR:	ALFONSO, FERDINAND		FACILITY TYPE:	735
ADDRESS:	833 DESCANSO WAY		TELEPHONE:	(415) 491-0226
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY: 4		CENSUS: 4	DATE:	04/28/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:27 PM
MET WITH:	Caregiver		TIME VISIT/ INSPECTION COMPLETED:	04:37 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Licensee not able to come to facility. LPA spoke to licensee via telephone, he gave caregiver permission to sign report. Facility currently has four (4) residents in care. Administrator Certificate for Ferdinand Alfonso is #7000212735 expires 6/2/27. LPA and caregiver discussed Emergency Disaster Plan, no updates were implemented. At approximately 1:45pm LPA and caregiver toured the building and grounds. The facility was at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found open and uncovered in the freezer, caregiver immediately stored open uncovered item in a ziplock bag. Most items in the refrigerator were stored in a safe manner. LPA noticed food located in staff room, per caregiver, only they eat the food in the staff room. LPA discussed with caregiver that snacks need to be readily available for residents, such that they can help themselves to food if they wish. No snacks were present in the facility. Cleaning products and laundry soaps are located in the staff room in a locked cabinet and inaccessible to residents in care. All bedrooms were equipped with lighting, night stand, and chest of drawers. Resident bathrooms had required bath mats and grab bars. Bathroom in back of facility has a leaking shower and leaking sink. Windows in rooms for residents (R2, R3, and R4) have black substance covering sills and black and gray substance is also present on the window screens and along the entire frame of the windows. Room for R4 is missing a window screen (deficiency cited, see 809D). Water temperature in sinks measured at 113.6 degrees F in the kitchen which is within the allowable range of 105 to 120 degrees F. LPA observed couch in Continued on 809C...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/28/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HACIENDA HOME	FACILITY NUMBER: 216890070
	VISIT DATE: 04/28/2026

NARRATIVE

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Continued from 809...
living room to be in disrepair, cushioning all worn, lumpy, missing in spots, and springs are felt when sitting. LPA suggested providing a comfortable couch for residents to sit on while in the living room. Fire extinguishers were last inspected 10/21/25. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drill was conducted on 4/10/26.

At approximately 2:35pm LPA and caregiver reviewed cash resources for R4. Per caregiver, licensee gets all the checks, cashes them, then leaves the money in an envelope for R4. LPA asked to see check stub to verify amount. Per caregiver, only licensee has stubs. LPA observed signature of R4 present on ledger indicating receipt of cash. LPA asked that licensee send to LPA copy of check stubs so LPA can verify amount of monies received on behalf of R4.

At approximately 2:45pm LPA conducted a review of four (4) out of four (4) resident files and one (1) staff record. Residents R1 and R3 do not have a current physician's report, however, R1 is not 60 years old (deficiency cited, see 809D).

At approximately 3:45pm LPA and Licensee conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. Filled dates missing from Centrally Stored Medication log (CSML). However, CSML are issued from pharmacy and medication is delivered in its own pouch for the day, they are filled all at one time. LPA and caregiver discussed still putting date filled date as it is required per regulation. LPA and caregiver discussed PRN MARs and the requirement to fill it out each time a PRM is administered. LPA showed caregiver example fo how to fill out PRN according to regulation requirements. LPA observed pre-poured medications (deficiency cited, see 809D).

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC500- Personnel Report
LIC308- Designation of Responsibility
Surety Bond

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with caregiver and a copy of this report was given.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/28/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/28/2026 04:23 PM - It Cannot Be Edited

Created By: Christi Coppo On 04/28/2026 at 04:03 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HACIENDA HOME	FACILITY NUMBER: 216890070
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and caregiver observation, the licensee did not comply with the section cited above in that Bathroom in back of facility has a leaking shower and leaking sink. Windows in rooms for residents (R2, R3, and R4) have black substance covering sills and black and gray substance is also present on the window screens and along the entire frame of the windows. Room for R4 is missing a window screen, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2026
	Plan of Correction
1 2 3 4	Facility to submit pictiures of cleaned (not painted over) window frames, sills, and screens in rooms for R2, R3, and R4 by plan of correction due date. Facility to submit work order from professional repair service for leaking shower and sink in back bath as well as paid invoice by plan of correction due date. Facility to submit picture of screen present in room for R4 by plan of correctiond due date.

Type B

Section Cited

CCR

85068.4(e)

Acceptance and Retention Limitations

(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)]. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review , the licensee did not comply with the section cited above in that R3 did not have a current physician's report, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2026
	Plan of Correction
1 2 3 4	Facility to submit current physician's report for R3 by plan of correction due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:

	Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 04/28/2026 04:23 PM - It Cannot Be Edited

Created By: Christi Coppo On 04/28/2026 at 04:03 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HACIENDA HOME	FACILITY NUMBER: 216890070
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(k)(5)

Health-Related Services

(k) The following requirements shall apply to medications which are centrally stored: (5) Each client's medication shall be stored in its originally received container. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in that LPA observed pre-poured medications, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/05/2026
	Plan of Correction
1 2 3 4	Facility to submit LIC9098 self-certifying they will immedicately cease pre-pouring medications.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:

	Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026

LIC809 (FAS) - (06/04)

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