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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601302
Report Date: 04/16/2025
Date Signed: 04/16/2025 01:28:59 PM

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
03/10/2025 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20250310213049
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: 171DATE:
04/16/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Sandra Simon, Executive DirectorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff did not refund the entrance fee as required by the continuing care contract
INVESTIGATION FINDINGS:
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On 04/16/2025 at around 1 p.m Licensing Program Analysts (LPAs) K. Nguyen and P. Manalo arrived at facility unannounced to deliver findings for the complaint investigation related to the above listed allegation. LPAs met with Executive Director, Sandra Simon and explained the purpose of the visit.

During the course of this investigation, the Department reviewed Acacia Creek Residence and Care Agreements, a California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities, an Assignment of Benefits Agreement form, Emergency Contact documentation, Pre-Admission Questionnaire, Physician’s Report, Mini-Mental State Examination report, entrance fee check copies, deposit check copies, bank account statements, Entrance Fee Refund Letter, refund checks, Deposit Worksheets and refund check calculation documents.

***Report Continued on LIC 9099c***

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
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-20250310213049
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: 04/16/2025
NARRATIVE
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The investigation revealed that Resident 1 (R1) entered into an agreement for residency at the community in June of 2016 and occupied a residential living unit for independent living until July of 2017 when he required a higher level of care. In July of 2017, R1 entered a skilled nursing facility affiliated with the community and remained there through the end of life until, March of 2019. To enter the community and receive the benefits of a continuum of care, R1 paid an entrance fee that is refundable based on a 36 month amortization. The beneficiaries to R1’s estate claim that the entrance fee should have been amortized based on the time frame beginning from entering into the agreement through entering into the skilled nursing facility, however the amortization was based on the date of death.

The Residence and Care Agreement, document number 1243823.17, was approved by the Department for use. It states under Section VI – Termination, subsection E Refund to Resident it states that “Any refund paid under this Section VI.E.1 shall be made within fourteen (14) days after all of the following events occur: (1) you or your estate makes your Apartment available to Acacia in its original clean condition ( excluding normal wear and tear); (2) if applicable, you vacate any facility operated by Acacia Creek Union City (ACUC) or Masonic Homes of California (MHC) pursuant to this Agreement; and (3) you or your estate executes a document releasing Acacia from any and all duties and obligations under this Agreement.”



In this case, R1, the subject of the complaint entered into a skilled nursing facility operated by MHC and therefore would not be entitled to refund. The allegation of “Staff did not refund the entrance fee as required by the continuing care contract” is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

An exit interview was conducted, and a copy of this report was given to Executive Director.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2