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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006383
Report Date: 12/11/2024
Date Signed: 12/11/2024 04:08:55 PM

Document Has Been Signed on 12/11/2024 04:08 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 ASC, 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:
12/11/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Jacklyn Concepcion - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:23 PM
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On 12/11/2024, LPA Dwayne Mason Jr arrived at the facility for the purpose of conducting a plan of corrections visit. On 10/28/2024, the facility was issued four citations as part of a complaint inspection and a case management visit. LPA reviewed documents and toured the facility.

LPA observed all exit doors to be unobstructed. LPA observed all medication was removed from the facility refrigerator. LPA received documentation for an in-service training conducted on 10/31/2024. LPA received complete LIC9182 for the staff that were previously not associated to the facility.

Based on today's visit, LPA determined the plans of correction previously issued were fulfilled. LPA cleared the deficiencies and reviewed this report with the Administrator. LPA also provided the facility with the deficiency clear letters.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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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