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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601302
Report Date: 03/07/2025
Date Signed: 03/25/2025 02:14:39 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, 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
12/04/2024 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20241204123458
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: 178DATE:
03/07/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Sandra C. Simonn, Excutive Director TIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Resident sustained injuries due to lack of care and supervision from staff
Staff did not ensure that resident's toileting needs were met
INVESTIGATION FINDINGS:
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*****THIS IS AN AMENDED REPORT FROM VISIT 3/7/25*****

On 3/25/2025 at 1p.m. Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced visit to deliver the findings for the above complaint allegation. LPA met with Sandra C. Simon, Excutive Director explained the purpose of the visit.

Allegation: Resident sustained injuries due to lack of care and supervision from staff: Unsubstantiated
On 3/07/2025, The department reviewed record of R1 including medical record, discharge summary, report and progress notes indicated R1 was admitted to ER due to an unwitnessed fall on 11/26/24. R1 was in the hospital

Report Continue on LIC9099...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
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 15-AS-20241204123458
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/07/2025
NARRATIVE
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*****THIS IS AN AMENDED REPORT FROM VISIT 3/7/25*****

On 3/7/2025, the department interviewed staff (S1), resident (R1), and owner of assisting hands home care agency (OSA). The department reviewed staff roster with contact numbers, physician's report, care plan, emergency information, progress notes, Unusual Incident/ Injury report (UIR), and resident dinner check off list to for date confirmation. R1 physician report shows R1 is independent with only need of toileting assist. R1 needs and service plan shows that R1 is not a fall risk and doesn’t need staff to come unless R1 press the pendant. S1 confirmed that S1 only attended to R1 only when R1 press the pendant. This was confirmed with R1 during the interview regarding to the facility care staff attending to R1 only when R1 press the pendant that’s when facility care staff comes. R1 stated the reason why R1 hired a private caretaker due companionship and for R1 personal needs such as clean R1 apartment daily, because the facility only cleans the apartment once a week. R1 want private caretaker to wash dishes daily, laundry, take out the trash, ect. R1 did not sustained any major injury, but R1 sustained minor cut on R1 eyebrow.

Allegation: Staff did not ensure that resident's toileting needs were met

On 3/7/2025, the department reviewed R1 care plan, and interviewed resident (R1), showed that R1 toileting needs were met. R1 care plan shows that R1 is not a fall risk and only press the pendant when R1 needs assistance from facility care staff. R1 stated “I have no complaint of any care staff because when I need assistance with toileting, they provided to me”. R1 stated staffs are very friendly and helpful.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
LIC9099 (FAS) - (06/04)
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