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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601302
Report Date: 05/22/2025
Date Signed: 06/18/2025 01:29:36 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
05/16/2025 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20250516101416
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: 175DATE:
05/22/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Viarmina Paje-Forsythe (Mina), Wellness Manager TIME COMPLETED:
12:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are keeping resident against their will.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
*****THIS IS AN AMENDED REPORT FROM VISIT 05/22/2025*****

On 05/22/2025 at around 10:00 am, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a complaint visit. LPA met with Wellness Manager, Viarmina Paje-Forsythe (Mina), and explained the purpose of the visit. LPA received via text from Executive Director Sandra Simon, for Mina to sign the report.

Allegation: Staff are keeping resident against their will - UNFOUNDED

During the course of the investigation, LPA K. Nguyen reviewed the resident roster from 2017- May 22, 2025. LPA conducted an interview with S1, S1 stated R1 never resided at the facility. A review of rosters reveals that the individuals involved in the incident are not residing 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. An exit interview was conducted, and a copy of this report was provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
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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