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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006383
Report Date: 12/05/2024
Date Signed: 12/05/2024 02:41:10 PM

Document Has Been Signed on 12/05/2024 02:41 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 GUEST HOME-ANAHEIMFACILITY NUMBER:
306006383
ADMINISTRATOR/
DIRECTOR:		CONCEPCION, JACKLYN PENG LFACILITY TYPE:
740
ADDRESS:1516 W LA PALMA AVENUETELEPHONE:
(626) 541-5921
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 5DATE:
12/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Emannuel GojarTIME VISIT/
INSPECTION COMPLETED:
04:14 PM
NARRATIVE
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LPA toured the inside and outside of facility with (AD) and observed the following:
The facility is a 4-bedroom, 2-bathroom, 1-story house with detached garage that is being used for storage. Resident Bedrooms: the 3 resident bedrooms are spacious and have all required furniture per regulations: Lights, chairs, linens, and storage for each resident bedroom. LPA found a pair of scissors, Skintegrity Spray for wounds and Clorox disinfectant wet napkins in one of the resident’s rooms. AD immediately removed and locked the items. The fourth bedroom is for staff and also had all required elements per regulation.

LPA toured the kitchen and observed grease and left over oil splashes on stove and around the oven; stove had five burners and only 4 worked due to grease and oil being stuck. AD tried to clean stove and was unable to make the burner work. 7 kitchen drawers were loose and not intact in place.

LPA checked restroom one and observed chipped paint in the shower area. Shower had a glass door which had mold and mildew around the rim and edges of the door. LPA checked water temperature and it was tested between 109.9 and 110.9 Degree Fahrenheit. LPA checked Carbon Monoxide, Smoke Detectors and all tested operational. Fire Extinguisher was in the green, fully charged, and last checked on July 17th, 2024. LPA checked food sully and the facility had the 2 days perishable and 7 days nonperishable food supply per regulation.

LPA toured the outside of the facility and observed a shaded area with chairs and space for residents’ activities and enjoyment. LPA found full bottle of Windex, and Clorox in a blue bucket and accessible to residents in care.

During record review, LPA observed that fire drills are conducted monthly. Staff records showed all required documentation including valid CPR.(..CONTINUE 809C....)

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 GUEST HOME-ANAHEIM
FACILITY NUMBER: 306006383
VISIT DATE: 12/05/2024
NARRATIVE
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 LPA checked three residents’ file and observed that 2 out of 3 residents had dementia and none had a recent physician report: Resident (R1) last physician report was 8/14/23 and R2 physician report was 06/08/2023.

Based on the observation made during today’s visit, deficiencies are being citied today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.


An exit interview was conducted, and a copy of this report was provided to the AD.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 12/05/2024 02:41 PM - It Cannot Be Edited


Created By: Samer Haddadin On 12/05/2024 at 02:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ACACIA GUEST HOME-ANAHEIM
FACILITY NUMBER: 306006383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above with leaving cleaning supplies in resident's room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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AD removed items and will provide training to staff and e mail LPA by POC due date
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by leaving scissors in resident' romm which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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AD secured the scissors and will provide training to staff and e mail LPA by poc due date
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Samer Haddadin
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 12/05/2024 02:41 PM - It Cannot Be Edited


Created By: Samer Haddadin On 12/05/2024 at 02:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ACACIA GUEST HOME-ANAHEIM
FACILITY NUMBER: 306006383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by leaving cleaning supplies in backyard and over the counter med in resident's room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Items were secured and AD will provide training and e mail LPA by POC due date
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Samer Haddadin
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 12/05/2024 02:41 PM - It Cannot Be Edited


Created By: Samer Haddadin On 12/05/2024 at 02:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ACACIA GUEST HOME-ANAHEIM
FACILITY NUMBER: 306006383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above by leaving grease and oil on oven and unsafe kitchen drawers not intact and falls if open which poses an potintail health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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AD will fix and clean kitchen drawers and grease and send profe via e mail to LPA by POC due date
Type B
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having mold in restroom and mildew all around the glass shower door which poses an potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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AD will clean and paint restroom and e mail profe to LPA via e mail by POC due date
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Samer Haddadin
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 12/05/2024 02:41 PM - It Cannot Be Edited


Created By: Samer Haddadin On 12/05/2024 at 02:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ACACIA GUEST HOME-ANAHEIM
FACILITY NUMBER: 306006383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having grease and broken kitchen drawers which poses an potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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AD will fix and e mail LPA by POC due date
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having annual physician report for 2/3 dementia residents which poses an potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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AD will obtain Phsician report and e mail LPA by POC due date
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Samer Haddadin
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


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