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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803511
Report Date: 08/12/2025
Date Signed: 08/13/2025 09:11:24 AM

Document Has Been Signed on 08/13/2025 09:11 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HACIENDA DEL MAR CARE HOMEFACILITY NUMBER:
486803511
ADMINISTRATOR/
DIRECTOR:		BALBUENA, AL Q.FACILITY TYPE:
740
ADDRESS:505 HACIENDA LANETELEPHONE:
(707) 434-1577
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 6CENSUS: 3DATE:
08/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:46 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
05:10 PM
NARRATIVE
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At approximately 12:45, Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a required annual inspection visit. LPA was greeted by administrator Al Balbuena. Facility is a Residential Care Facility for the Elderly that has a fire clearance approved for six residents. Facility currently has three residents which were all attending day program during visit.

LPA and admin toured the building and grounds which was found to be clean and in good repair. Facility was clean and at a comfortable temperature. LPA observed all walkways and exits to be unobstructed. All required postings were in a highly visible area. Fire extinguishers were charged and last inspected 4/9/2025. Fire alarms and carbon monoxide detector were tested and operational. Outdoor emergency exit clear from obstruction. LPA observed no outdoor furniture or chairs to be accessible for residents. LPA had conversation with admin that residents must have accessible seating area.

LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable foods. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. LPA observed some food missing expiration dates. LPA had conversation with admin that all food must have expiration dates noted.
Toxins were observed to be unlocked under kitchen sink. Lysol spray and wipes observed to be unsecured and accessible to residents in the living room. LPA observed gallon bottle of bleach and gallon bottle of multi-purpose cleaner in walkway of backyard (Deficiency Cited, See 809D). Sharps and knives were in kitchen drawer without a lock. Staff stated drawer is locked while residents are home and LPA had conversation that lock must be on regardless if residents aren't home.

Emergency water and food supply was stored in garage. Facility had an ample supply of linens, towels and extra hygiene products for residents. All bedrooms were equipped with lighting, a night stand and chest of drawers. All bedrooms were clean and in good repair. Bathroom accessible to residents had required bath mat and grab bar. Communal towel observed to be found in bathroom and no soap. Bathroom located in resident room did not have paper towels,bath mat or soap. LPA had conversation with admin about the provisions of maintenance services for all bathrooms accessible to residents.

Continued onto 809C...
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HACIENDA DEL MAR CARE HOME
FACILITY NUMBER: 486803511
VISIT DATE: 08/12/2025
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Continued from 809....

Water temperature measured at 105.2 degrees F at faucets accessible to residents which is within the allowable range of 105 to 120 degrees F. Disaster drills not being conducted quarterly with last drill conducted on 8/16/2024 (Deficiency Cited, See 809D).

LPA reviewed 3 of 3 resident records. All required documentation was present. Physician reports were up to date.

LPA reviewed 3 staff records. S1 and S2 did not have required Health Screening( LIC503), Personnel Record (LIC501) and TB Clearance. S2 and S3 did not have required First Aid Certification (Deficiency Cited, See 809D).

LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:



LIC500- Personnel Report
LIC308-Designation of Responsibility
Liability Insurance

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

Exit interview conducted and report read with Administrator.

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/13/2025 09:11 AM - It Cannot Be Edited


Created By: Ethel Contreras On 08/12/2025 at 03:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in that tKnife drawer did not have lock. Chemicals under sink observed to be unlocked, Lysol spray and disinfectant wipes observed to be in living room accessble to residents. Gallon bottle of Clorax Bleach and gallon bottle of Multi-Purpose Cleaner Solution on floor in walkway of backyard
which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2025
Plan of Correction
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Licensee to submit LIC9098 self certifying that all chemicals must be kept locked and inaccessible to residents by Plan of Correction due date 8/13/2025 to CCL.
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and admin record review, the licensee did not comply with the section cited above in that S2 and S3 does not have First Aid Certification which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2025
Plan of Correction
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Licensee to submit self certification that staff are signed up to take First Aid Cerification Course by Plan of Correction Due date 8/13/2025. Licensee to submit First Aid/CPR Certification for S2 and S3 by 8/29/2025 to CCL.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/13/2025 09:11 AM - It Cannot Be Edited


Created By: Ethel Contreras On 08/12/2025 at 03:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and record review the licensee did not comply with the section cited above in that there is No LIC503, LIC501 and TB Clearance for S1 and S2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2025
Plan of Correction
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Licensee to submit LIC503,LIC501 and TB Clearance for S1 and S2 to CCL by Plan of Correction due date 9/01/2025.
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 onLPA observation and record review, the licensee did not comply with the section cited above in that disaster drills are not being conducted quarterly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2025
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 Plan of Correction due date 9/01/2025
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2025


LIC809 (FAS) - (06/04)
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