<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603404
Report Date: 06/08/2026
Date Signed: 06/08/2026 04:25:54 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/22/2026 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20260522093149
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:
06/08/2026
UNANNOUNCEDTIME BEGAN:
11:49 AM
MET WITH: Jacklyn Peng Lee Concepcion - AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not provide resident with comfortable accommodations.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit regarding the allegations listed above. LPA met with James Alfonso Loppies, Caregiver and explained the purpose of the visit. Shortly after, Administrator, Jacklyn Peng Lee Concepcion arrived and the purpose of the visit was explained.
The investigation consisted of the following: On 05/28/2026, LPA toured the facility, obtained and reviewed the staff and resident rosters, Staff schedule, Staff orientation checklist and training logs, ADL schedules, Resident #1 (R1) - Resident #5 (R5) files suchas as Identification and Emergency information/Face sheet, Resident appraisal, Admission agreement, Physician's report, Medication Administration Records (MARs for April & May 2026),Physician's orders and Care plans.
During today's visit, LPA toured the facility, obtained the staff and resident rosters, Unusual incident/injury report (May 2026). LPA interviewed Staff #1 (S1) - Staff #2 (S2) and Resident #1 (R1) - Resident #4 (R4). LPA attempted to interview Resident #5 (R5) but unsuccessful due to no response. Resident #6 (R6) just arrived as a new resident at the time of the visit. ******CONTINUED ON LIC9099-C*****
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20260522093149
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ACACIA GUEST HOME
FACILITY NUMBER: 198603404
VISIT DATE: 06/08/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The investigation revealed the following:

Allegation: Staff do not provide resident with comfortable accommodations. It is alleged that residents appeared to be neglected and were often kept confined to their rooms without proper monitoring or routine care checks. Staff interviewed stated that there’s adequate staffing but due to the facility's recent renovations, staff acknowledged that they did not allow residents to leave their rooms or offer activities despite conducting regular safety checks on the residents. Staff indicated that they haven't been able to encourage the residents to take part in various activities because there aren't any activities planned for the residents. Residents interviewed stated that they spend all day in their rooms listening to music or watching television. Some residents stated that they typically stay in their rooms because there were no activities offered to them. Documents reviewed revealed that the facility lacked a documented care plan to monitor safety checks and routine care for residents, especially incontinent residents. Additionally, the medication administration records (MARs) were not documented properly including not initialing the medications that were administered. Although LPA did not observe uncomfortable accommodation during the facility inspection, it was observed that despite having (2) staff members on duty, residents were not encouraged to leave their rooms to socialize or engage in any activities. Therefore, there was sufficient evidence to corroborate with this allegation.

Based on LPA’s observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was provided to the Administrator, Jacklyn Peng Lee Concepcion, along with the Appeal Rights.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20260522093149
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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: 06/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/22/2026
Section Cited
CCR
87468.2(a)(8)
1
2
3
4
5
6
7
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator to ensure that residents will not be confined in their rooms, staff provide activities, care and supervision necessary to meet their needs, and to review and understand the Title 22 regs. 87468.2. Administrator to develop daily planned activities for the residents which will be posted in the facility and will send a copy to CCL/LPA by POC due date.
8
9
10
11
12
13
14
Based on observation, interviews, records review, the Administrator did not comply with the section cited above in which the residents were neglected as they were kept confined in their rooms, and were not provided a variety of planned activities which poses a potential health, safety or personal rights risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3