198603404-4-9-2024-28-AS-CDCN-D474EA-20240409190202

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603404
Report Date: 04/09/2024
Date Signed: 04/09/2024 07:02:39 PM

Document Has Been Signed on 04/09/2024 07:02 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 HOME		FACILITY NUMBER:	198603404
ADMINISTRATOR:	CONCEPCION, JACKLYN PENG L		FACILITY TYPE:	740
ADDRESS:	1847 ACACIA HILL ROAD		TELEPHONE:	(909) 895-7807
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY:	6	CENSUS: 6	DATE:	04/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Maura Demapan, Staff		TIME COMPLETED:	04:00 PM

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	Licensing Program Analysts (LPAs) Cynthia Chan and Christian Gutierrez conducted the required annual inspection using the CARE tools. LPA arrived unannounced and met with staff, Maura Demapan, 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. LPAs toured the facility, reviewed records, and interviewed 2 staff and 2 residents. The following were observed: Infection Control: The facility staff are using gloves when needed to assist residents. Facility has sufficient PPE supplies. Staff receive Infection Control training annually. 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. There is one resident on hospice and 2 receiving 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 swimming pool on the premises. There are 5 resident bedrooms, 1 live-in staff room with bathroom, 1 communal bathroom, living room, dining room, kitchen, laundry area, 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. The hot water temperature 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. Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed the Administrator and 2 other staff files. There were sufficient annual training on file. CPR & First Aid certificates are current for all 3 staff.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ACACIA GUEST HOME	FACILITY NUMBER: 198603404
	VISIT DATE: 04/09/2024

NARRATIVE

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Resident Records-Incident Reports: Resident files are maintained at the facility. LPAs reviewed all 6 resident files and they have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-admission appraisal, and Resident rights.
Resident Rights-Information: The Local Ombudsman and Residents personal rights information are posted 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 in their original containers. LPAs reviewed 6 residents' medications and there are discrepancies found for 3 of the residents (Resident #2, #4, and #5). Some of the medications were not properly marked on the MAR log as given. Also, some of the medications did not appear to be given as prescribed, as the medications were still in the bubble pack. The start date noted on the bubble pack did not correspond to today's date.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and procedures. .
Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. There are currently 1 resident on hospice.

A deficiency was issued on the LIC809D. An exit interview was held with the Administrator via telephone. A copy of this report, LIC809D, and appeal rights were given to the staff.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 04/09/2024 07:02 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(a)

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in which 3 out of 6 residents' medications were not properly administered as prescribed nor properly documented which poses an immediate health and safety risk to persons in care.
	POC Due Date: 04/10/2024
	Plan of Correction
1 2 3 4	The licensee shall conduct a staff training on medication distribution and documentation. The log shall be submitted to LPA by 4/10/24.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

LIC809 (FAS) - (06/04)

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