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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001602
Report Date: 06/22/2022
Date Signed: 06/22/2022 06:19:56 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/22/2022 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20220622161315
FACILITY NAME:KELLY ACACIO'S CARE HOMEFACILITY NUMBER:
347001602
ADMINISTRATOR:ACACIO, LYNDALEFACILITY TYPE:
735
ADDRESS:8333 HOLLY JILL WAYTELEPHONE:
(916) 395-9279
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 6DATE:
06/22/2022
UNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Kelly Acacio, LicenseeTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Air conditioner broken and licensee not repairing it during excessive heat wave
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 6/22/22 at 5pm to conduct a Complaint Investigation. LPA was met by Caregiver Enrique Antiporda and stated the purpose of the visit. LPA and Caregiver toured the home.

LPA observed 6 residents and 3 portable fans and a broken Air Conditioner. Only 1 resident room contained a working portable fan. LPA observed the wall thermomstat to read 71*F, however, LPA measured the room near the kitchen to be at 89.2.


The Kelly Acacio, Licensee arrived within 30 minutes and stated the AC in 1 resident room is working, the circuit breaker tripped because it was on 1 hour ago. The AC unit was ordered and 2 portable AC units will be purchased today. Licensee shall ensure a hydration station is available for residents to stay hydrated.



Substantiated
Estimated Days of Completion: 30
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20220622161315
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: KELLY ACACIO'S CARE HOME
FACILITY NUMBER: 347001602
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2022
Section Cited
CCR
80088(a)(1)(A)
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Furniture, Fixtures, Equipment, and Supplies
A comfortable temperature for clients shall be maintained at all areas. The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C). In areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature.
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Licensee confirmed he will purchase 2 additional portable AC's for the home today. He has ordered a new AC Unit. Licensee shall fax purchase receipt to CCL once received from the electrician obtain additional water to be set out to ensure residents have the ability to hydrate. Receipts to be fax by tomorrow as POC.
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This requirement is not met as evidenced by: Licensee admitted the AC Unit has been broken for 1 week and additional fans/AC portable unit are needed.
Based on observation the temperature inside the home with 3 fans working is not within the range required by the regulations. This violation poses an immediate health, and safety risk to residents 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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 27-AS-20220622161315
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: KELLY ACACIO'S CARE HOME
FACILITY NUMBER: 347001602
VISIT DATE: 06/22/2022
NARRATIVE
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Based on observation during this visit and confirmation from the Licensee that the AC is broken for 1 week since last Saturday, the preponderance of evidence standards has been met; therefore, the above allegation(s) is found to be SUBSTANTIATED.

A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3