306004749-12-14-2024-22-AS-JCAN-DBXTSF-20241214135904

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004749
Report Date: 12/14/2024
Date Signed: 12/14/2024 01:59:13 PM

Document Has Been Signed on 12/14/2024 01:59 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	TOTAL ENROLLED CHILDREN: 0	CENSUS: 97	DATE:	12/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:47 AM
MET WITH:	ADMINISTRATOR TAMMY JOO		TIME VISIT/ INSPECTION COMPLETED:	02:30 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	On 12/14/2024 at 08:30 AM, Community Care Licensing Division (CCLD) staff conducted an unannounced annual inspection visit at Acacia Villas Facility. CCLD staff was allowed entry into the facility by Administrator Tammy Joo. The facility is licensed for 99 residents 60 years or older. Currently there are 97 resident living at the facility. CCLD staff explained to Administrator Tammy Joo, the purpose of the 1-year Annual Inspection visit, and escorted CCLD staff on a tour of the entire inside and outside facility grounds. As part of the inspection, CCLD staff reviewed: ten (10) resident service records, ten (10) resident medication records, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 12/12/2024. The two-story commercial building consisting of (66) resident bedrooms, (66) resident bathrooms, (4) common bathrooms, dining room, TV room, commercial kitchen, staff room, office area, commercial washer and dryer/ storage area, backyard with umbrella with table and chairs. No weapons were found or stored on the premises. Commercial Kitchen was inspected and observed to be clean and operational. CCLD staff checked commercial refrigerators and storage for 2-day supply perishable and 7-day supply of non-perishable foods are present in the facility kitchen. Emergency Water Storage was also located in the kitchen area. CCLD staff inspected resident room 101, 102, 109, 202, 206. CCLD staff observed that all resident rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. CCLD staff observed the following during inspection of resident’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, CCLD staff observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. CCLD staff observed bathrooms were found to be within Title 22 regulation.

Ulysses Coronel	TELEPHONE: (323) 400-7397
Jose Calderon	TELEPHONE: (323) 213-1153
	DATE: 12/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024

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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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: 12/14/2024

NARRATIVE

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Bathroom #1 hot water temperature properly measured at 109 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 107 degrees Fahrenheit. Bathroom #3 hot water temperature properly measured at 105 degrees Fahrenheit. Kitchen water temperature properly measured at 115 degrees Fahrenheit. Facility (10) Carbon Monoxide and (80) Smoke Detectors hard wired and connected were tested and are working properly. The facility (12) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the facility were free of debris and hazards. Outside patio accessible to residents. Ten (10) resident files were reviewed and found to be complete. CCLD staff reviewed ten (10) resident medications and they were all found to be administered according to doctor's orders. Five (5) staff files were checked and have the required documents. CCLD staff noted the Administrator Tammy Joo Certification # 6021814740 expiration date of 12/13/2024 was NOT valid at time of inspection. The facility does not handle resident's money/cash resources. Commercial General Liability Policy #PCI2995184802 policy period from 09/05/2024 to 09/05/2025 underwritten by Primary Care Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. Administrator Tammy Joo to email CCLD staff a full copy of the commercial insurance policy including all endorsements no later than 12/30/2024. All the required documents are posted in the facility in a clearly visible area.

During the visit, CCLD staff observed the facility infection control practices. CCLD staff observed screening protocols for visitors, staff, and residents, sanitizing stations (Located in common areas and restrooms). CCLD staff observed staff and residents were not wearing face coverings. CCLD staff observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

CCLD staff advised the Administrator Tammy Joo to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.
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According to the California Code of Regulations (Title 22, Division 6, Chapter 8), CCLD staff did not observe deficiencies therefore no citations were issued at this time. Annual Licensing Fee is CURRENT. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Tammy Joo.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024

LIC809 (FAS) - (06/04)

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