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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803511
Report Date: 08/13/2024
Date Signed: 08/13/2024 11:45:31 AM


Document Has Been Signed on 08/13/2024 11:45 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
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: 4DATE:
08/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Maria Machica (caregiver)TIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Required – 1 Year inspection and was greeted by Maria Machica, Caregiver. Administrator Al Balbuena was not available to come to the facility, but gave authorization for staff to sign the report. All fees are current as of this time.

LPA/staff toured the building and grounds at 9:30 AM. The facility was found to be clean and a comfortable temperature, passageways free from obstructions. There is a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food. Water temperature measured 106.7 & 105.1 degrees F which is within regulation between 105 and 120 degrees F. There was an ample supply of linens, hygiene and paper products available for residents. Toxins were inaccessible to residents in a locked cabinet in the garage. All resident's bathrooms contained necessary grab bars and non-slip floors/mats. Medication is centrally stored in a locked cabinet in a room off the kitchen area. All bedrooms are equipped with lighting and proper bedding which was clean and in good repair. Fire extinguisher was last inspected November 2023. Smoke detectors and carbon monoxide located throughout the facility were tested and operational. Exit doors have auditory alerts. No disaster drill conducted within the last quarter.

LPA initiated file review at 10:00am of 4 resident and 1 staff records. Staff have required CPR/1st aid certificate and required training hours. However, other staff files were not in the facility available for review. Per Administrator, files were taken by him to update them (Technical violation issued). One out of four residents do not have a care plan on file (Technical violation issued). Medical assessments for all residents are current. A spot check of Medication and medication records was also conducted at 10:35 AM. Al Balbuena Administrator Certificate 6029935740 expires 3/12/2026.

Administrator agreed to submit copies of the following documents by 8/23/24: LIC500- Personnel Report, LIC308- Designation of Responsibility, Copy of Current Lease Agreement and copy of Liability Insurance.

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. Exit interview conducted with Administrator via phone and a copy of this report was given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
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 08/13/2024 11:45 AM - 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: 08/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Administreator observation, interview and record review, the licensee did not comply with the section cited above in having a disaster drill conducted within the last quarter, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Administrator will conduct a disaster drill and will send a self-certification form (LIC9098) to CCL ensuring that the facility is within compliance by POC due date (8/23/24) to clear the citation.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
LIC809 (FAS) - (06/04)
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