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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803511
Report Date: 09/01/2022
Date Signed: 09/01/2022 03:08:55 PM


Document Has Been Signed on 09/01/2022 03:08 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 3DATE:
09/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Al BalbuenaTIME COMPLETED:
03:17 PM
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Licensing Program Analyst (LPA) Katrina Walters conducted an unannounced Required - 1 Year inspection of this licensed senior care facility. LPA was initially greeted by caregiver. Administrator/Licensee, Al Balbuena (6029935740 exp 3/11/2024) was contacted and arrived later. This facility has submitted an updated copy of their infection control plan to Community Care Licensing.

LPA toured the building and grounds which were found to be clean and in good repair. At primary entrance LPA observed temperature log and visitor sign in sheet. LPA observed COVID postings and hand sanitizer throughout facility. Facility has designated a space for visitors to meet with residents. All residents have their own bedroom in the event that they need to isolate. Facility provides ongoing training to staff regarding infection control and informs staff of updated PIN's. LPA reviewed staff training which indicated that at least one staff has first aid, CPR and medication training. Staff S1 also has been vaccinated and proof of vaccination is stored in staff binders. LPA conducted interviews with resident R1 and S1 as apart of this inspection.

Fire Extinguisher was found to be last charged on November 01, 2021 at the time of the visit. Facility smoke detectors and carbon monoxide detectors that were found to be functioning properly at the time of the visit. LPA is requesting that Administrator sends an updated LIC 500, Liability Insurance, and LIC 308 to Santa Rosa Community Care Licensing attention LPA Walters

Exit interview conducted with Licensee/Administrator Al Balbuena. LPA was unable to print. Report was emailed to administrator/licensee.No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
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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