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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803511
Report Date: 08/11/2021
Date Signed: 08/11/2021 11:59:41 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:HACIENDA DEL MAR CARE HOMEFACILITY NUMBER:
486803511
ADMINISTRATOR:BALBUENA, AL Q.FACILITY TYPE:
740
ADDRESS:505 HACIENDA LANETELEPHONE:
(707) 434-1577
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:6CENSUS: 4DATE:
08/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:TIME COMPLETED:
12:15 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 Analysts (LPA), Katrina Walters arrived unannounced to conduct an Annual inspection and was greeted by staff. Administrator, Al Q Balbuena (6029935740 exp. 3/11/2022) arrived later. LPA conducted a risk assessment prior to entering the facility. The inspection is focused on the Infection Control procedures and practices of this facility. This facilities COVID-19 mitigation plan has been submitted and approved by Community Care Licensing (CCL).

Upon entry, LPA was screened for COVID-19 symptoms and had temperature checked prior to entering. Alcohol based hand wash was available for visitors. All staff are screened daily, daily screenings are logged in a facility binder. LPA conducted a walk through of facility with S1 and made the following observations: Facility had all required postings visible for visitors. Additional posters were posted throughout the facility to promote hand washing and social distancing. Bathrooms were stocked with hand soap and paper towel. Per Administrator all Staff have completed Personal Protective Equipment (PPE), infection control training. Facility has 30+ day supply of PPE, medication and incontinence supplies. Facility is cleaned daily and high touch surfaces are cleaned each shift and after every meal.

Facility was a comfortable temperature and exits were free from obstructions. Fire Extinguisher was found to be last charged on October 23, 2020 at the time of the visit. All Facility smoke detectors and carbon monoxide detectors that were found to be functioning properly at the time of the visit.

Continued on 809 C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: HACIENDA DEL MAR CARE HOME
FACILITY NUMBER: 486803511
VISIT DATE: 08/11/2021
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
LPA is requesting the Administrator submits the following to LPA Walters by 8/16/21: A copy for residents R1's medication prescription.

No deficiencies observed or cited during today's Required 1- Year inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2