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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004749
Report Date: 06/13/2022
Date Signed: 06/13/2022 10:44:13 AM


Document Has Been Signed on 06/13/2022 10:44 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:ACACIA VILLASFACILITY NUMBER:
306004749
ADMINISTRATOR:TAMMY JOOFACILITY TYPE:
740
ADDRESS:1620 E. CHAPMAN AVENUETELEPHONE:
(714) 879-0920
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:99CENSUS: 83DATE:
06/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Michelle Kwak, Tammy JooTIME COMPLETED:
10:55 AM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting an Annual Inspection. LPA met with facility staff Michelle Kwak and Administrator (AD) Tammy Joo and discussed the purpose of the inspection. During the inspection, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, laundry room, and kitchen and observed the following:

During the inspection, LPA and AD observed there were 20 staff present, wearing PPE. LPA observed 83 residents were present. LPA confirmed residents were doing well and observed no health and safety issues. LPA inspected common areas, resident rooms, laundry room, and kitchen, and observed they were clean and organized, and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed hallways and walkways were free of obstruction.

LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, staffing, infection control/lead/training, PPE, staffing and staffing shortages, and communication and emergency plan. LPA provided technical assistance regarding N95 fit testing, physical plant, staff files, and storage. LPA requested and reviewed resident roster, staff roster, staff files, resident files, emergency plan, and COVID-19 mitigation plan.

There were no health and safety concerns observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
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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