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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803511
Report Date: 06/03/2025
Date Signed: 06/03/2025 03:31:42 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/28/2025 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20250228165924
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:
06/03/2025
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Al Balbuena, AdministratorTIME COMPLETED:
03:31 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not assisting resident after they fall, leaving them for long periods of time
Staff are not feeding resident
Staff are not meeting resident's care needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced on 06/03/2025 to deliver findings of the complaint investigation regarding the above allegations. LPA Nakagawa requested records, conducted interviews and made observations. LPA met with Administrator Al Balbuena and discussed the findings.
The complaint alleges that Staff are not assisting resident after they fall, leaving them for long periods of time. LPA conducted interviews with resident R1 who was unable to recall specific dates and times of incidents where staff left them for long periods of time. LPA inspected staffing records and found staff present at all times. Other residents stated that staff are responsive to their needs in a timely manner and reported the observation of staff helping R1.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
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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