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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006383
Report Date: 12/19/2023
Date Signed: 12/19/2023 10:20:13 AM

Document Has Been Signed on 12/19/2023 10:20 AM - 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 GUEST HOME-ANAHEIMFACILITY NUMBER:
306006383
ADMINISTRATOR:CONCEPCION, JACKLYN PENG LFACILITY TYPE:
740
ADDRESS:1516 W LA PALMA AVENUETELEPHONE:
(626) 541-5921
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 3DATE:
12/19/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Zepta Tamba, Jacklyn Peng L ConcepcionTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Staff #1 (S1) Zepta Tamba, discussed the purpose of the inspection, and toured the facility. Applicant (AP) Jacklyn Peng L Concepcion arrived during the inspection. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 07/13/2023. This is a change of ownership with persons in care.

During the inspection, LPA and AP observed the following: Structure: facility is a 4-bedroom, 2-bathroom, 1-story house with detached garage that is being used for storage. Facility telephone number is (714) 671-8329. Resident Bedrooms: the 3 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Lights, chairs, linens, and storage for each resident bedroom inspected. Staff Bedrooms: the 1 staff bedroom is spacious and will easily accommodate the staff’s furnishings. Bathrooms: were clean, faucets and toilets were operational. Water temperature: tested at 109 degrees F in the resident bathroom. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: 2 days perishable and 7 days nonperishable food supply reviewed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen drawer. Toxins: observed locked in the kitchen and garage. Medication cabinet is locked. First-Aid Kit & Activity Supplies: observed and available. Resident & Staff Files: LPA reviewed 3 resident files and 1 staff file. Fire clearance was approved by Anaheim Fire Department on 09/08/2023. Backyard exit gate is operational and unlocked. Backyard has shaded area for outdoor activities and sufficient seating for residents. Component III was completed with AP during today’s inspection. Facility is currently operating under the liability insurance of current facility ANGEL ROSE RESIDENCE (306005228). AP will switch liability insurance to new facility once the application is approved.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ACACIA GUEST HOME-ANAHEIM
FACILITY NUMBER: 306006383
VISIT DATE: 12/19/2023
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During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AP was informed today that the facility is ready for licensure and final approval will be processed by the CAB supervisor in Sacramento. An exit interview was conducted and a copy of this report was discussed with and provided to AP.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC809 (FAS) - (06/04)
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