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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004749
Report Date: 12/24/2024
Date Signed: 12/24/2024 04:07:48 PM

Document Has Been Signed on 12/24/2024 04:07 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: 98DATE:
12/24/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:42 PM
MET WITH:Michelle Kwak, Tammy JooTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
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This unannounced 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 12/24/24. 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 the residents present and confirmed they were doing well 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. LPA observed the electricity and water were running, the medications were properly stored, and the facility had soap and paper towels. LPA requested and reviewed copies of the resident roster, staff roster, and resident files.

Facility representative was advised that at this time further investigation is required. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
Armando J LuceroTELEPHONE: (714) 703-2840
Sean HaddadTELEPHONE: (714) 335-7094
DATE: 12/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/24/2024
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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