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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601302
Report Date: 05/29/2024
Date Signed: 05/29/2024 02:11:12 PM


Document Has Been Signed on 05/29/2024 02:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CITYFACILITY NUMBER:
015601302
ADMINISTRATOR:CHUCK MAJORFACILITY TYPE:
741
ADDRESS:34400 MISSION BLVD.TELEPHONE:
(510) 441-3700
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:376CENSUS: 159DATE:
05/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Chuck Major, Excutive DirectorTIME COMPLETED:
02:35 PM
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At around 9:30am, Licensing Program Analyst (LPA) Kelly Nguyen arrived unannounced to conduct annual required inspection and met with Administrator Chuck Major. LPA explained to Administrator purpose of the visit.

The facility has a main building consists of 5 floors and 4 cottages. The resident apartments were located on the first 4 floors of the main building and 4 cottages. Dining room, bar, game room and board room are all located on the 5th floor.

LPA with Administrator inspected 5 rooms. The facility has a swimming pool and spa that were locked and enclosed. Administrator states that there is no lifeguard on duty. However, there are cameras installed in the area. The facility was observed to be clean and odor free. Administrator states that residents have pendants or use their telephone, if they need assistance. Out of 159 residents, 6 are in the assisted living. There were multiple fire extinguishers observed that appear full and were last serviced on 01/17/2024. The last fire alarm inspection was conducted on 4/26/2024.

There was sufficient supply of perishable and non-perishable foods observed. Freezer temperature was observed at -2- and 0-degrees Fahrenheit. Refrigerator temperature measured at 37.5- and 35.4-degrees Fahrenheit. First aid kit was observed complete. Vehicle insurance and registration were verified as current.
continuation on Lic 809C

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/29/2024
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LPA reviewed 6 staff files 6 out of 6 staffs have health clearance on files. LPA reviewed 6 residents files.

No deficiencies were observed in the areas that were evaluated. No citations were issued during today’s inspection.

Exit interview conducted and a copy of this report provided via email to Executive Director.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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