015601302-4-14-2023-15-AS-LFOA-CQVV4K-20230414160627

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601302
Report Date: 04/14/2023
Date Signed: 04/14/2023 04:06:40 PM

Document Has Been Signed on 04/14/2023 04:06 PM - 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	ACACIA CREEK - UNION CITY		FACILITY NUMBER:	015601302
ADMINISTRATOR:	CHUCK MAJOR		FACILITY TYPE:	741
ADDRESS:	34400 MISSION BLVD.		TELEPHONE:	(510) 441-3700
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	376	CENSUS: 154	DATE:	04/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Chuck Major		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At around 9am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct annual required inspection and met with Administrator Chuck Major. LPA explained to Administrator purpose of the visit. LPA Leslie Ibo was also present during this visit. The facility has a main building consists of 5 floors and 4 cottages. The resident apartments were located on the first 4 floors of the main building and 4 cottages. Dining room, bar, game room and board room are all located on the 5th floor. LPAs with Administrator inspected 5 rooms. The facility has a swimming pool and spa that were locked and enclosed. Administrator states that there is no lifeguard on duty. However, there are cameras installed in the area. The facility was observed to be clean and odor free. Administrator states that residents have pendants or use their telephone, if they need assistance. Out of 154 residents, 7 are in the assisted living. There were multiple fire extinguishers observed that appear full and were last serviced on 1/11/2023 . The last fire alarm inspection was conducted on 2/8/2022 . There was sufficient supply of perishable and non perishable foods observed. Freezer temperature was observed at -2 and 0 degrees Fahrenheit. Refrigerator temperature measured at 37.5 and 35.4 degrees Fahrenheit. First aid kit was observed complete. Vehicle insurance and registration were verified as current. continuation on Lic 809C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ACACIA CREEK - UNION CITY	FACILITY NUMBER: 015601302
	VISIT DATE: 04/14/2023

NARRATIVE

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At 11:30 am , LPAs reviewed medication and Medication Administration Record (MAR) with facility nurse.

At approximately 1:15 pm, LPAs interviewed 5 staff and 2 out of 5 residents. At 2:30 pm, LPAs reviewed 5 resident files and 5 staff files.

The following deficiencies were observed:

at 10:51 am, 10:53 am and 11:05 am, LPAs observed housekeeping carts with chemicals were left unlocked and unattended in the hallways
at 11:25 am, LPAs observed freezer cleaner stored in the non perishable foods storage

Deficiencies were cited per Title 22 California Code of Regulations.

Exit interview was conducted with Administrator and Appeal Rights was provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 04/14/2023 04:06 PM - 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ACACIA CREEK - UNION CITY	FACILITY NUMBER: 015601302
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in failing to lock chemicals in the housekeeping carts which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2023
	Plan of Correction
1 2 3 4	Staff locked all chemicals in the 3 housekeeping carts during inspection. The deficiency is cleared,

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 04/14/2023 04:06 PM - 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ACACIA CREEK - UNION CITY	FACILITY NUMBER: 015601302
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(25)

General Food Service Requirements

(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in failing to store freezer cleaner in area separate from non perishable foods which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2023
	Plan of Correction
1 2 3 4	Facility removed freezer cleaner from the food storage area during visit. This deficiency is cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

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