486803511-4-11-2023-21-AS-HDBI-CQU2QZ-20230412173645

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803511
Report Date: 04/11/2023
Date Signed: 04/11/2023 10:20:20 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/31/2023 and conducted by Evaluator Victoria Bertozzi

COMPLAINT CONTROL NUMBER: 21-AS-20230131115814

FACILITY NAME:	HACIENDA DEL MAR CARE HOME		FACILITY NUMBER:	486803511
ADMINISTRATOR:	BALBUENA, AL Q.		FACILITY TYPE:	740
ADDRESS:	505 HACIENDA LANE		TELEPHONE:	(707) 434-1577
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	6	CENSUS: 3	DATE:	04/11/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Licensee, Al Balbuena		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility not providing basic services

INVESTIGATION FINDINGS:

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Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above complaint allegation and was greeted by staff. Licensee, Al Balbuena arrived later.

Facility not providing basic services – Complaint alleges that facility does not provide healthy meals to residents and does not accommodate their restricted diets. Per file review, two of three residents have special diets. Of the two, one physician’s report identifies the “special” diet but the other does not detail what the diet should be. Two of three residents are identified as being diabetic. Review and analysis of grocery receipts provided by the facility for January and February of 2023 show that facility did not consistently purchase food that would meet Recommended Dietary Allowances.

Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

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

LIC9099 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/31/2023 and conducted by Evaluator Victoria Bertozzi

COMPLAINT CONTROL NUMBER: 21-AS-20230131115814

FACILITY NAME:	HACIENDA DEL MAR CARE HOME		FACILITY NUMBER:	486803511
ADMINISTRATOR:	BALBUENA, AL Q.		FACILITY TYPE:	740
ADDRESS:	505 HACIENDA LANE		TELEPHONE:	(707) 434-1577
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	6	CENSUS: 3	DATE:	04/11/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Licensee, Al Balbuena		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Personal Rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above complaint allegation and was greeted by staff. Licensee, Al Balbuena arrived later.

Personal Rights – Complaint alleges that residents are “verbally degraded” by staff. LPA spoke with staff and residents and received conflicting accounts on staff interactions with residents. LPA was unable to confirm if staff are speaking to residents in a way that would violate resident’s personal rights.

A finding that the complaint allegation that staff are violating resident's personal rights was unsubstantiated meaning that although the allegation may have happened there is not a preponderance of evidence to prove that the allegations occurred.

No deficiencies cited.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230131115814

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 DEL MAR CARE HOME	FACILITY NUMBER: 486803511
	VISIT DATE: 04/11/2023

NARRATIVE

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Continued from LIC9099

During today's visit, LPA observed the contents of both refrigerators and found that facility did not have enough vegetables to meet the requirements of regulation.

The allegation of Facility not providing basic services is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 21-AS-20230131115814

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 DEL MAR CARE HOME	FACILITY NUMBER: 486803511
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/18/2023 Section Cited CCR 87464(f)(3)	1 2 3 4 5 6 7	87464(f)Basic services shall at a minimum include: (3) Three nutritionally well-balanced meals and snacks made available daily, including low salt or other modified diets prescribed by a doctor as a medical necessity, as specified in Section 87555, General Food Service Requirements.	1 2 3 4 5 6 7	Facility agrees to submit a planned menu that meets the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council by POC due date, 4/18/2023
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by LPA observation and receipt review and interviews showing that facility is not providing meals that meet Recommended Dietary Allowances. This is a potential risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC9099 (FAS) - (06/04)

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