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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004749
Report Date: 01/02/2025
Date Signed: 01/02/2025 03:46:20 PM

Document Has Been Signed on 01/02/2025 03:46 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ACACIA VILLASFACILITY NUMBER:
306004749
ADMINISTRATOR/
DIRECTOR:		TAMMY JOOFACILITY TYPE:
740
ADDRESS:1620 E. CHAPMAN AVENUETELEPHONE:
(714) 879-0920
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY: 99TOTAL ENROLLED CHILDREN: 0CENSUS: 97DATE:
01/02/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:32 AM
MET WITH:Michelle Kwak, Tammy JooTIME VISIT/
INSPECTION 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
This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on December 24, 2024, regarding Resident #1 (R1). LPA met with Staff #1 (S1) Michelle Kwak and explained the purpose of the inspection. Administrator (AD) Tammy Joo arrived during the inspection.

During the inspection, LPA and AD toured the facility. LPA conducted health and safety checks on R1 and the other residents present and confirmed they were doing well and observed no health and safety issues. LPA interviewed AD, R1, and witnesses, and requested and reviewed copies of the resident roster, staff roster, an Incident Report received December 24, 2024, R1’s Physician’s Report dated June 21, 2024, and R1’s Appraisal dated January 02, 2025. The investigation into the incident revealed the following. Per interview with AD and an Incident Report received December 24, 2024, on December 17, 2024, R1 was diagnosed with a fractured clavicle after an unwitnessed fall at the facility. Interviews with AD and a witness and review of R1’s Physician’s Report dated June 21, 2024, revealed that on June 21, 2024, R1 was readmitted to the facility after receiving treatment at a skilled nursing facility for a stroke and had fall risks related to the stroke. Per AD and a witness, the facility and R1’s family created a fall prevention plan around June 21, 2024, to address R1’s fall risks related to the stroke which included moving R1’s room to the first floor and more frequent checks, private one-on-one caregivers, and furniture and equipment in R1’s room to address possible falls. AD and the witness also stated that after R1’s fall on December 17, 2024, the facility and R1’s family updated R1’s fall prevention plan to include additional private one-on-one caregivers and additional alterations to furniture and equipment in R1’s room to address possible falls. Per R1’s Appraisal dated January 02, 2025, the facility properly reassessed R1 after R1’s change in condition relating to the fall on December 17, 2024. However, AD admitted that R1’s Appraisal was not updated in writing after R1’s readmission on June 21, 2024 to document the fall prevention plan put in place to address R1’s change in condition and fall risks related to the stroke.
Armando J LuceroTELEPHONE: (714) 703-2840
Sean HaddadTELEPHONE: (714) 335-7094
DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2025
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ACACIA VILLAS
FACILITY NUMBER: 306004749
VISIT DATE: 01/02/2025
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
Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights 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: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/02/2025 03:46 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: ACACIA VILLAS
FACILITY NUMBER: 306004749

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/02/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87463 Reappraisals (a) The pre-admission appraisal… shall be updated in writing as frequently as necessary … to note significant changes in condition… and to keep the appraisal accurate…
Deficient Practice Statement
1
2
3
4
POC Due Date: 01/30/2025
Plan of Correction
1
2
3
4
Licensee stated they will create a protocol for updating residents’ appraisals in response to changes in condition, train relevant staff on the protocol, and submit proof to LPA by POC due date.
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.
Armando J LuceroTELEPHONE: (714) 703-2840
Sean HaddadTELEPHONE: (714) 335-7094

DATE: 01/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2025

LIC809 (FAS) - (06/04)
Page: 3 of 3