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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601302
Report Date: 12/05/2024
Date Signed: 12/05/2024 03:41:13 PM

Document Has Been Signed on 12/05/2024 03:41 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/
DIRECTOR:		CHUCK MAJORFACILITY TYPE:
741
ADDRESS:34400 MISSION BLVD.TELEPHONE:
(510) 441-3700
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 376TOTAL ENROLLED CHILDREN: 0CENSUS: 160DATE:
12/05/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Sandra Simon, Excutive Director TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 12/05/24 at 2:15PM, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced Health and Safety check due to the department receiving a priority 2 complaint. LPA explained the purpose of the visit with Executive Director, Sandra Simon.

During the health and safety check, LPA observed facility is preparing for the tree light event. LPA toured facility with Executive Director, including but not limited to bedrooms, kitchen, dining rooms, activities rooms, bathroom, outdoor garden and common areas. LPA observed residents comfortable in their surroundings, relaxing in their apartment, and common areas with family and friends. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during the health and safety check.

Exit interview conducted and a copy of this report provided.
Bennett FongTELEPHONE: (510) 725-7919
Kelly NguyenTELEPHONE: (510) 915-8702
DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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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