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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006383
Report Date: 10/17/2024
Date Signed: 10/17/2024 12:21:46 PM

Document Has Been Signed on 10/17/2024 12:21 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: 6DATE:
10/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Jacklyn Concepcion - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On 10/17/2024, LPA Dwayne Mason Jr arrived at the facility for the purpose of conducting a case management visit for deficiencies. LPA was greeted and granted entry by facility staff. LPA met with Administrator (AD) Jacklyn Concepcion and explained the purpose for the visit.

LPA reviewed Guardian and the Licensing Information System. Based on record review, LPA observed the two staff members working at the facility at the time of the inspection are not associated to the facility. LPA noted both staff members have obtained their criminal record clearance, but are not associated to the Acacia Guest Home-Anaheim facility.

Based on today's inspection, one deficiency is being issued. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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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Document Has Been Signed on 10/17/2024 12:21 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 10/17/2024 at 11:14 AM
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: 10/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/24/2024
Section Cited
CCR
81019(e)(3)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 81019(f); This requirement is not met as evidenced by
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Administrator stated they will associate all facility staff to the facility by the assigned POC due date.
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Based on a record review, the licensee did not comply with the section cited above as two out of two staff members present at the facility were not associated to the facility. This poses/posed a potential health, safety or personal rights risk to persons in care.
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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:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
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