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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006383
Report Date: 10/28/2024
Date Signed: 10/28/2024 03:52:40 PM

Document Has Been Signed on 10/28/2024 03:52 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:
10/28/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Jacklyn Concepcion - Administrator, Briayn Yosjaya and Brandy Guinto, CaregiversTIME VISIT/
INSPECTION COMPLETED:
04:07 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a Case Management visit for the purpose of issuing deficiencies observed. LPA met with Caregivers Briyan Yosjaya and Brandy Guinto.

While at the facility, LPA reviewed the staff members associated at the facility. LPA observed a staff member working at the facility at the time of the visit was not associated to the facility. LPA verified the staff member is cleared to work in CCLD facilities, but the staff member was not associated to the facility. A citation is being issued.

While at the facility, LPA observed unlocked medication in the facility refrigerator. LPA determined the medication was accessible to residents in care. A citation is being issued.

While at the facility, LPA observed two doors blocking emergency exits from the facility. LPA noted doors were not blocked in a way that prevents any resident from accessing the rest of the facility. A citation is being issued.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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 10/28/2024 03:52 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 10/28/2024 at 03:23 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: 10/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2024
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 one 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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Type B
11/04/2024
Section Cited
CCR87307(d)(6)

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(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:

Based on observations, two doors leading from resident rooms to outside the facility
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Facility staff stated they will unobstruct both doors by the assigned POC due date.
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were observed to be obstructed by a bed frame and box spring in one room. The other room's door was blocked by a small dresser.
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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: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/28/2024 03:52 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 10/28/2024 at 03:29 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: 10/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2024
Section Cited
CCR
87465(h)(2)

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(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

Based on observations, the Licensee did not
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Administrator stated they will move medication to another refrigerator in a room with a lock or that they would purchase a lock box in order to safely store medication. AD stated they will notify LPA upon completion of plan.
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comply with the section cited above due to medication being stored in the refrigerator without being locked.
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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: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
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