<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881444
Report Date: 10/17/2024
Date Signed: 10/17/2024 11:36:47 AM


Document Has Been Signed on 10/17/2024 11:36 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 ASC, 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: 2DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Bernadette Balungcas, Administrator TIME COMPLETED:
11:45 AM
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
On 10/17/24 at 8:43am, Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct an annual inspection/1 year required visit. LPA was greeted and granted entry by Licensee Lupo Leyva and Bernadette Balungcas, where LPA explained the purpose of the visit. At the time of the visit there was (2) Staff and (0) clients present, as the clients were at the day program.

The facility is licensed to serve age range 18-59, and an approved fire clearance for (2) ambulatory and (2) non ambulatory clients in room 4. The facility was observed to be clean clutter and odor free. The passageways, are free from obstruction. There are no pools or bodies of water or guns and ammunition on the premises. The facility was observed to have fully charged fire extinguishers. The last emergency disaster drill was conducted on 09/15/24. The hot water temperature was tested and measured to be 111.7-113.7 degrees Fahrenheit. The smoke and carbon monoxide detectors were tested and observed to be operable.

Medications were observed to be locked and inaccessible to clients in care. Per the Medication Authorization Record (MAR), the medications are being given as prescribed. The chemicals, sharps and other hazardous items were observed to be locked and inaccessible to clients in care. The facility was observed to an ample supply of personal hygiene and personal protective equipment (PPE) supplies.
Records review: Staff: All staff present were observed to have obtained criminal record clearance and associated to the facility. Staff possessed valid Cardio Pulmonary Resuscitation certification that expires on 3/15/25, in addition to having valid Administrator certification, and additional training such as Direct Support Professional training completed.
Clients: both client files were observed to have admission's agreement, preadmission appraisal, medical assessment and Individual Program Plan (IPP). The Personal and Incidental (P&I) funds were verified. LPA observed for both clients to be over the age of 59 and informed the Licensee to contact the placing agency and ask for assistance to mitigate the current need. Per the Licensee Both C1 and C2 were moved from the
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HAYDEN HOME
FACILITY NUMBER: 371881444
VISIT DATE: 10/17/2024
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
26
27
28
29
30
31
32
Sister facility as there was a change in their ambulatory status. The Licensee will update the department in regards to the plan of action on which direction the facility is going to proceed, and agreed to contact the placing agency by close of business day (5pm) today. LPA advised the Licensee to contact the department with any questions or scenarios that arise so that proper guidance can be given.

In addition LPA observed for the facility to be utilizing video surveillance, in the common areas of the facility, which is noted in the facility's plan of operation or program statement. The Licensee already obtained the consents for each client in care. LPA informed Licensee that the facility sketch needs to be updated to reflect/indicate where the cameras are throughout the facility. An updated sketch was provided at the time of LPAs visit.

An exit interview was conducted and a copy of this report, and confidential names list (LIC811), was provided to Licensee Berandette Balungcas.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2