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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603404
Report Date: 03/21/2023
Date Signed: 03/21/2023 04:22:30 PM

Document Has Been Signed on 03/21/2023 04:22 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ACACIA GUEST HOMEFACILITY NUMBER:
198603404
ADMINISTRATOR:CONCEPCION, JACKLYN PENG LFACILITY TYPE:
740
ADDRESS:1847 ACACIA HILL ROADTELEPHONE:
(909) 895-7807
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: 6DATE:
03/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Jae Maralit, Head StaffTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection using the CARE tools. LPA arrived unannounced and met with staff, Jae Maralit, who allowed entry. The purpose of the visit was explained. The facility is licensed for 6 non-ambulatory residents, ages 60 and over, of which 1 may be bedridden. The hospice waiver is approved for 3 residents.

LPA toured the facility, reviewed records, and interviewed 2 staff and residents. The following were observed: Infection Control: The facility staff are aware of appropriate hand hygiene and when gloves should be worn. Facility has sufficient PPE supplies. LPA requested for the Infection Control Plan to be submitted by 3/28/23.
Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 6 residents residing at the facility which 2 are receiving hospice care and 2 home health services. The facility has the sufficient amount for liability insurance covering injury to residents and guests.
Physical Plant & Environment Safety: The facility does not have any bodies of water or pool on site. There are 5 resident bedrooms, 1 live-in staff room with bathroom, 1 communal bathroom, living room, dining room, kitchen, and attached garage. Facility has operable smoke detectors and a carbon monoxide detector located in the dining area. Knives, cleaning solutions, and disinfectants are locked. There are no firearms or weapons stored at the facility. The hot water temperature in the bathroom was measured between the required range of 105-120 degrees F.
Staffing: The administrator's (Jacklyn Concepcion) certificate expires on 7/21/24. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.
Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed the Administrator and 2 other staff files. LPA did not see sufficient annual training verification in their files. The CPR/First Aid certificates for all 3 personnel had expired.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
Document Has Been Signed on 03/21/2023 04:22 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 03/21/2023 at 02:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ACACIA GUEST HOME
FACILITY NUMBER: 198603404

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which 3 out of the 3 staff files reviewed did not have current CPR/first aid certification which poses a potential health and safety risk to persons in care.
POC Due Date: 04/07/2023
Plan of Correction
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Licensee shall arrange CPR/First Aid course for all employees who have expired certificates and submit proof of certification by 4/7/23.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 staff files did not have the number of training hours required annually which poses a potential health and safety risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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The licensee shall review all staff (including Administrator) files to ensure the required training hours are maintained. The POC is due 3/31/23.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 03/21/2023 04:22 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 03/21/2023 at 02:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ACACIA GUEST HOME
FACILITY NUMBER: 198603404

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of the 5 resident files reviewed did not have the current physician's report which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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The licensee shall obtain a current medical assessment for resident #5 by POC due date 3/31/23.
Type B
Section Cited
CCR
87468(c)(2)(A)
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which the complaint poster was not posted at the facility which poses a potential personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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The licensee shall submit proof that the RCFE Complaint Poster is posted by the main entryway of the facility by 3/31/23.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023


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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ACACIA GUEST HOME
FACILITY NUMBER: 198603404
VISIT DATE: 03/21/2023
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Resident Records-Incident Reports: Resident files are maintained at the facility and 4 out of the 5 files have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-admission appraisal, and Resident rights. Resident #5 is missing the current Physician's Report.
Resident Rights-Information: The Local Ombudsman and Residents personal rights information are posted at the facility. However, LPA and staff did not observe the Licensing Complaint poster at the facility.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical/mental capability.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The foods are properly stored in the refrigerator.
Incidental Medical & Dental: The medications are centrally stored and in their original containers. LPA reviewed 4 residents' medications and they are being administered as prescribed by the physician.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers. LPA requested for administrator to transfer information onto the updated LIC610E form.
Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. There are currently 2 residents on hospice.

Deficiencies are issued on the LIC809D. Technical advisory notes were also given.
An exit interview was held with the Administrator via telephone. A copy of this report, LIC809D, appeal rights, and technical advisory notes were given to Staff Maralit.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
LIC809 (FAS) - (06/04)
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