306004749-7-10-2026-22-AS-RMRT-DVUU8F-20260710152129

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004749
Report Date: 07/10/2026
Date Signed: 07/10/2026 03:21:38 PM

Document Has Been Signed on 07/10/2026 03:21 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ACACIA VILLAS		FACILITY NUMBER:	306004749
ADMINISTRATOR/ DIRECTOR:	TAMMY JOO		FACILITY TYPE:	740
ADDRESS:	1620 E. CHAPMAN AVENUE		TELEPHONE:	(714) 879-0920
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92831
CAPACITY: 99		CENSUS: 98	DATE:	07/10/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Tammy Joo, Administrator (AD)		TIME VISIT/ INSPECTION COMPLETED:	03:30 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 Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry at 8am by the Med Tech. LPA met with Tammy Joo, Administrator (AD) and explained the purpose of the visit. AD stated they recently had an Annual Required Evaluation on April 16, 2026 which was for 2025. LPA explained that the annual today would be for 2026 and AD understood. The facility is a two story building with an approved fire clearance for 99 non-ambulatory residents and an approved hospice waiver for thirty residents. LPA obtained the resident and staff roster and currently there are 98 residents in care and eleven on hospice. The facility accepts the Assisted Living Waiver. During today’s visit, LPA inspected the physical plant and reviewed fire sprinkler system and fire alarm inspection documentation. The fire sprinklers were tested on July 9, 2026 and passed. The fire alarms were inspected and passed on June 17, 2025. The facility's last fire drill was conducted on April 14, 2026. LPA observed fire extinguishers throughout the facility and they were charged and inspected on December 12, 2025. Southern California Edison had been working on a power line nearby and the facility's electricity was temporarily turned off for approximately ten minutes prior to lunch. LPA observed fire magnetic doors closing, the elevator defaulted to the first floor and residents were able to exit elevator and sit in the dining room for lunch. All hands assisted residents to the dining room until the electricity turned back on. The facility generator switched on during the temporary electrical shut-off. LPA toured the facility which consists of a large dining room and kitchen, a television room and offices on the first floor. There is one elevator and an enclosed courtyard with a shaded seating area. There were no (Continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ACACIA VILLAS	FACILITY NUMBER: 306004749
	VISIT DATE: 07/10/2026

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(Continued from LIC 809)

hazards or obstructions in pathways. Emergency supplies were observed in the kitchen and office area by
the front door. There are four stairwells and all stairwells had evacuation chairs. The facility was seventy eight degrees Fahrenheit. On the second floor LPA observed an activities room and theater and residents were observed in activities. LPA tested carbon monoxide detectors throughout the facility and all were in working order. The PUB 475 See Something, Say Something poster was posted in a prominent place; as well as the Long Term Care Ombudsman poster; which was in English and Korean. The facility also had cameras in common areas such as in the lobby, kitchen, med room and upstairs and downstairs hallways. Residents are informed during the admissions process and sign that they were informed. Cameras are visual only.

LPA inspected the kitchen and there are modified diets and resident eating habits posted near the beverage area. The kitchen extinguisher was charged. Sharps and knives were secured and LPA observed two days of perishable food supplies and seven days of non perishable food items. Temperature logs were observed on the refrigerators and freezers and the kitchen was sanitary. LPA entered resident apartments and noted they had the required furnishings and linens. LPA tested the hot water temperatures in five of five apartments. The water temperatures ranged from 105.1 to 119.4 degrees Fahrenheit and the facility recently bought a water heater booster. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. A First Aid Kit and manual were located in the Medication Room with the required elements.

LPA reviewed five of five staff training and fingerprint records and five of five resident records. Medical Assessments and Emergency Disaster Form LIC 610E was updated. The next staff Cardiopulmonary Resuscitation (CPR) training is scheduled for July 17, 2026. Staff are trained monthly by outside vendors and the community retains a nurse to review medical records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on December 13, 2026.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Tammy Joo, Administrator and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026

LIC809 (FAS) - (06/04)

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