306004749-11-20-2024-22-AS-AORZ-DB9N3S-20241122090650

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004749
Report Date: 11/20/2024
Date Signed: 11/20/2024 03:46:50 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/16/2023 and conducted by Evaluator RoseMarie Ruppert

COMPLAINT CONTROL NUMBER: 22-AS-20230316094636

FACILITY NAME:	ACACIA VILLAS		FACILITY NUMBER:	306004749
ADMINISTRATOR:	TAMMY JOO		FACILITY TYPE:	740
ADDRESS:	1620 E. CHAPMAN AVENUE		TELEPHONE:	(714) 879-0920
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92831
CAPACITY:	99	CENSUS: 97	DATE:	11/20/2024
		UNANNOUNCED	TIME BEGAN:	03:10 PM
MET WITH:	Tammy Joo, Administrator (AD)		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Resident is not receiving showers

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced complaint visit to investigate the allegations that were received in our office on March 16, 2023. LPA was greeted and granted entry into the facility by the concierge and met with Tammy Joo, Administrator (AD) and stated the purpose of the visit.

During the investigation LPA obtained and reviewed the following documents: the resident roster, shower schedules from February and March 2023 and current shower schedules and itemized resident invoices that were provided by the accountant. LPA also reviewed seven of seven resident Admissions Agreements, Needs and Services Plans, Identification forms and Assisted Living Waiver (ALW) Medical Assessments.

(Continued on LIC 9099-C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie Ruppert	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230316094636

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/20/2024

NARRATIVE

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(Continued from LIC 9099)

It was alleged facility resident is not receiving showers due to Resident 1 (R1) not receiving showers. The Long Term Care Ombudsman (LTCO) assisted LPA in translating interviews of five of six residents regarding shower services received and itemized billing for services. All six residents interviewed verified they received showers on their scheduled day and get additional showers in the week beyond the two showers as agreed upon.

LPA spoke with three staff members regarding shower schedules and all confirmed showers were being given. LPA reviewed current shower schedules, as well as from February and March 2023, which notated each resident is receiving two showers per week. AD Joo & Business Office Manager Michelle Kwak confirmed the shower schedules get updated every two weeks. LPA was unable to interview R1 due to R1 having passed. Based on evidence reviewed, preponderance of evidence shows residents are receiving showers.

This agency has investigated the complaint alleging residents are not receiving showers. The Department found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted with Tammy Joo, Administrator (AD) and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie Ruppert	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024

LIC9099 (FAS) - (06/04)

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