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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004749
Report Date: 05/29/2024
Date Signed: 05/29/2024 01:01:28 PM


Document Has Been Signed on 05/29/2024 01:01 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:TAMMY JOOFACILITY TYPE:
740
ADDRESS:1620 E. CHAPMAN AVENUETELEPHONE:
(714) 879-0920
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:99CENSUS: 95DATE:
05/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Tammy JooTIME COMPLETED:
01:15 PM
NARRATIVE
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This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of a health and safety check and to follow up on a self-reported incident report received in the Orange County Regional Office (OCRO) on May 23, 2024 regarding an incident involving Resident #1 (R1). LPA met with Administrator (AD) Tammy Joo and discussed the purpose of the inspection. During today’s inspection, LPA toured the facility with AD. LPA conducted health and safety checks on the residents present and observed no health and safety issues. LPA observed the facility to be 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, the electricity and water were running, the facility had soap and paper towels, and the medications, sharps, and toxins were properly stored. LPA conducted interviews and requested and reviewed copies of the resident roster, staff roster, and resident files. The investigation into the incident revealed the following: on May 22, 2024, R1 left the facility during the overnight shift without being observed by staff, staff immediately noticed and called police, police found R1 about an hour or less later nearby the facility and took R1 to a hospital, R1 sustained no serious injuries, and R1 was moved out of the facility and relocated to a memory care unit. Per R1’s Physician’s Report, they were not able to leave the facility unassisted. AD stated that R1 had no history of wandering, facility staff had been conducting checks on R1 and other residents regularly, and when R1 left the alarm on the door went off and facility staff, who had recently just seen R1, checked for R1 again and noticed they had left, and the facility acted immediately to notify police and look for R1 within the facility, which resulted in R1 being found very close to the facility, very quickly, and with no injuries. 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: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
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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Document Has Been Signed on 05/29/2024 01:01 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: 05/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/05/2024
Section Cited
CCR
87464(f)(1)

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87464 Basic Services … (f) Basic services shall at a minimum include: (1) Care and supervision... This requirement was not met as evidenced by:
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Licensee stated they will create a list of residents who are unable to leave the facility unassisted and retrain staff on the elopement protocol and submit proof to LPA by POC due date.
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Based on interview and documents, the licensee did not provide adequate supervision to R1 when R1 eloped, was missing for a short period of time, and was found nearby with no injuries, which poses a potential safety risk to persons in care.
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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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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