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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881444
Report Date: 08/23/2023
Date Signed: 08/23/2023 10:46:35 AM

Document Has Been Signed on 08/23/2023 10:46 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HAYDEN HOMEFACILITY NUMBER:
371881444
ADMINISTRATOR:BALUNGCAS, BERNADETTEFACILITY TYPE:
735
ADDRESS:515 S HAYDEN DRIVETELEPHONE:
(858) 888-1050
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 4CENSUS: 0DATE:
08/23/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lupo Leyva and Bernadette Balungcas - LicenseeTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Sara Martinez conducted an announced visit to complete the Pre-licensing inspection. LPA met with Licensee, Lupo Leyva and Bernadette Balungcas for an Adult Residential Facility with a capacity of four (4) residents.

The facility is a six (6) bedroom, four (4) bath home. There are four (4) client bedrooms, two (2) staff rooms, kitchen/dining area, one (1) living room area, a laundry room, and backyard. LPA toured the interior and exterior areas of the facility. The following were inspected:

Client Bedrooms: All bedrooms have the required bedding and furniture, such as, clean mattresses/linen, nightstands, dressers, chairs, lighting, and emergency lighting.

Client Bathrooms: The bathroom appliances were operating in safe and sanitary condition. The bathrooms have non-slip mats.

Kitchen and Dining Areas: Utensils and dishware are in good repair and ready for client use. Kitchen appliances and counter top were free of debris and in good repair. The knives and sharp objects were locked in the drawers. The water temperature was measured by LPA, the thermometer read at 115 degrees F.

Common Sitting Areas: There is adequate seating in the common areas. The facility has a a schedule for activities for the clients posted and a adequate amount of activities at the facility. The common seating area has a storage locker that will hold client files, staff files, and medication.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HAYDEN HOME
FACILITY NUMBER: 371881444
VISIT DATE: 08/23/2023
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Laundry Room: The laundry room is near the kitchen area and will be locked at all times. The chemicals and laundry soap will be locked away in a the laundry room and requires a passcode for entry.

Linens and Hygiene Supplies: An adequate supply of linens were available.

Backyard: The facility does not have any bodies of water on the property. There is a covered area with seating for the all the clients. All passageways were free from obstruction.

Fire extinguisher, carbon monoxide, firearms: There are five (5) charged fire extinguishers in the facility. LPA observed operating smoke detectors and carbon monoxide alarms. The home does not have any firearms and ammunition.

Postings: LPA observed required postings including the visitation polices, emergency/disaster plans, complaint procedures, and personal rights.

First aid and working telephone: The facility was equipped with a complete first aid kit and manual. The facility has working telephone for client use.

LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPA have determined that the facility meets the operational requirements for licensure. The Pre-licensing inspection is complete, and this facility has no deficiencies. The facility has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Licensees Lupo Leyva and Bernadette Balungcas
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
LIC809 (FAS) - (06/04)
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