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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 03:41:38 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:
03:33 PM
ALLEGATION(S):
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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:
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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. LPA found no corroborating evidence that R1 had fallen and left for a long period of time. Although the allegation may have happened there is not a preponderance of evidence therefore, the allegation that staff are not assisting resident after they fall, leaving them for long periods of time is unsubstantiated.
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)
Page: 1 of 2
Control Number 21-AS-20250228165924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/03/2025
NARRATIVE
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Continued from 9099....

The complaint alleges that Staff are not feeding resident. LPA interviewed staff and residents who stated that residents generally eat meals together at the dining room table, although residents R2 and R3 attend Day Program Monday through Friday and have lunch at that site. It was reported by staff S1 and S2,and clients R2 and R3 that R1 usually eats with them but sometimes refuses meals. LPA inspected the kitchen on 03/05/2025 and 06/03/2025 and found an adequate supply of perishable and non-perishable food. Although the allegation may have happened there is not a preponderance of evidence therefore the allegation that staff are not feeding resident is unsubstantiated.

The complaint alleges that the Staff are not meeting resident’s care needs. LPA reviewed care notes and conducted interviews with R1’s care team who stated that R1 regularly refuses medical treatments. Facility staff have documented the refusals and inform care providers and emergency personnel when there is a change in condition. Records indicate staff provide care and support of R1 therefore the allegation that Staff are not meeting resident’s care needs is unsubstantiated.

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
LIC9099 (FAS) - (06/04)
Page: 2 of 2