Hacienda Del Mar Care Home

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a 1- year required inspection and was greeted by administrator (Admin) Al Balbuena. Facility is a Residential Care Facility for the Elderly that has a fire clearance approved for six residents. Facility currently has 5 residents residing. LPA and staff toured the building and grounds which was found to be clean and in good repair. Facility was 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 4/17/2026. Fire alarms and carbon monoxide detector were tested and operational. Outdoor emergency exit clear from obstruction. 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 with expiration dates noted. Toxins are stored in a locked cabinet and inaccessible to residents. Sharps and knives were locked in kitchen drawer. Emergency water and food supply was stored in garage. There were snacks accessible for residents. 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. Resident bathroom had required bath mat and grab bar. Water temperature measured at faucets accessible to residents is within the allowable range of 105 to 120 degrees F. Disaster drills are being conducted. Continued onto 809C.... continued from 809.... LPA reviewed 5 out of 5 resident records. All required documentation was present. 3 out of 5 Physician Reports (LIC602) were not up to date (Deficiency cited, see 809D). LPA reviewed 3 staff records. All required documentation was present. LPA and admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. 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 are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided. Exit interview conducted and report read with Administrator.the state’s words, verbatim · CDSS document, Sep 1, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(h) · Plan of correction due date: Sep 15, 2026

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by: Based on record review and observation the licensee did not comply with the section cited above in 3 out of 5residents did not have annually updated medical assessment and service plan in file which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 1, 2026

Plan of correction: Licensee or Administrator to submit to CCL completed and updated medical assessment for all three residents to CCL by POC due date of 9/15/2026.

Type of visit: Required - 1 Year

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... 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.the state’s words, verbatim · CDSS document, Aug 12, 2025

Allegation investigated: 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

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 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.the state’s words, verbatim · CDSS document, Jun 3, 2025 · control 21-AS-20250228165924

Allegation investigated: 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

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 Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 3, 2025 · control 21-AS-20250228165924

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Aug 13, 2024

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.