486803511-9-7-2023-21-AS-DTOA-CVFSPH-20230907140310

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803511
Report Date: 09/07/2023
Date Signed: 09/07/2023 02:03:18 PM

Document Has Been Signed on 09/07/2023 02:03 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 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:	09/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Al Balbuena, Licensee		TIME COMPLETED:	02:15 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	On 9/7/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by Licensee, Al Balbuena. The facility is single story building licensed for 3 non-ambulatory residents, one bed-ridden resident and a hospice waiver of two. The facility currently provides care for three residents, one of which was present and two of which were on community outings or appointments at the time of visit. There are currently no residents receiving hospice services but some of which have a diagnosis of dementia. LPA continued with a tour of the facility with Lead Staff and Licensee, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 11/8/2022. Both smoke detectors and carbon monoxide detectors throughout the facility were tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with additional food supplies in the garage. Facility also follows appropriate dietary protocol for resident in care. Toxins were located in the garage and laundry room both of which were found to be secured. LPA toured the facility backyard and found all bedroom screens in good repair and found one emergency exits located in the side yard to be clear and unobstructed. Resident was observed interacting with staff in the common area, enjoying lunch and resting in their bedroom while LPA conducted inspection. Relations between staff and resident are positive and resident appears to be comfortable. There was a supply of hygiene products and paper products available for residents. All resident bedrooms have lighting & appropriate furnishings. Medications located in dinning area were found to be secured. LPA conducted spot medication count and found several medications for 3 out of 3 residents not properly input or completed on the Centrally Stored Medication Records. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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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Document Has Been Signed on 09/07/2023 02:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 486803511
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(6)

The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 3 resident records. Facility failed to properly input prescription medicaiton information on the Centrally Stored Medication Records which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/15/2023
	Plan of Correction
1 2 3 4	Licensee agrees to reconsile all prescription medication to be properly input on the Centrally Stored Medicaiton Records for 3 out of 3 residents. Copies of the Centrally Stored Medicaiton Records of residents' current medicaitons are to be submitted to CCLD by POC date 9/15/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HACIENDA DEL MAR CARE HOME	FACILITY NUMBER: 486803511
	VISIT DATE: 09/07/2023

NARRATIVE

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LPA conducted a file review for all 3 out of 3 residents and found all Physician's Reports updated. LPA found that resident (R1) requires an updated Needs & Service Plan to account for recent changes of medical conditions. Technical Violation issued. In addition, LPA Tobola requested for Licensee to ensure signatures for all resident personal rights forms. Technical Assistance provided. LPA also conducted a sample staff file review and found staff (S1) in need of an updated 1st Aid & CPR certification. Technical Violation issued.

Licensee, Al Balbuena's Administrator Certification 6029935740 is valid until 3/11/2024.

LPA requested the following documents be sent to CCL by COB 10/7/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Control of Property

Deficiency 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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC809 (FAS) - (06/04)

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