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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601302
Report Date: 06/28/2023
Date Signed: 06/28/2023 10:23:20 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/21/2023 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20230621153006
FACILITY NAME:ACACIA CREEK - UNION CITYFACILITY NUMBER:
015601302
ADMINISTRATOR:CHUCK MAJORFACILITY TYPE:
741
ADDRESS:34400 MISSION BLVD.TELEPHONE:
(510) 441-3700
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:376CENSUS: 147DATE:
06/28/2023
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Chuck Major, AdministratorTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are abusing residents in care.
Staff are mismanaging resident's medications.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 06/27/2023 at approximately 9:35 am Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit meeting with Chuck Major, Administrator and explained the propose of the visit.

During the course of the investigation, LPA J. Clancy-Czuleger reviewed the staff and resident roster. A review of rosters reveals that the individuals involved in the incident do not work or reside at this facility therefore the above allegation is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

No deficiency observed or cited during this visit. Exit interview conducted and a copy of this report provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023
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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