015601302-8-29-2023-15-AS-KHOS-CVZRKZ-20230925130623

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601302
Report Date: 08/29/2023
Date Signed: 08/29/2023 12:07:09 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
06/14/2023 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20230614162518

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: 147	DATE:	08/29/2023
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Chuck Major, Administrator		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff do not safeguard resident's personal items

INVESTIGATION FINDINGS:

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On this day, Aug. 28, 2023 at 11:50AM Licensing Program Analyst (LPA) K. Nguyen deliver the finding on the above allegations, while delivering the first finding to Chuck Major Administrator.

Allegation: Staff do not safeguard resident's personal items

During the course of investigation LPA interviewed staff and 4 residents. LPA attempted to interview 2 other residents but was refused to be interview. LPA obtained 6 residents’ agreements. 6 out of 6 residents’ agreements have residents’ signatures that acknowledged that they understand the policy of the facility. LPA reviewed facility agreement on page 11 numeral IX: Miscellaneous section 3 (property damage) stated, “Acacia shall not be responsible for the loss of or damage to any property belonging to you due to theft, fire, or any cause beyond the control of Acacia. You are required to obtain insurance protection to cover the full replacement value of all your personal property at the Community, and to furnish Acacia with evidence of such protection upon request. Yon shall also be responsible for any loss or damage that you or your guests cause to the property of the Community that is not the result of ordinary wear and tear”. 4 out of 4 residents stated that have not requested the facility to safeguard their property upon arriving.

Report continue on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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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Control Number 15-AS-20230614162518

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: 08/29/2023

NARRATIVE

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Based on the information gathered, there was not a substantial amount of evidence to prove that the facility staff do not safeguard resident’s personal items. 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.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

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