<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001602
Report Date: 08/30/2024
Date Signed: 08/30/2024 01:25:13 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/14/2024 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20240814022242
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: 5DATE:
08/30/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Kelly AcacioTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not keep the facility free from a rodent and bug infestation
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/30/24, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to complete and delivery findings for a complaint investigation with the allegation above. LPA met with Licensee Kelly Acacio and discussed the conclusion for complaint and the findings.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on interviews and record reviews, it was learned that the facility has a recurring issue with bed bugs and rodents. The licensee corroborated that despite trying to remove the bed bugs and rodents by spraying and setting traps, it hasn't fixed the problem. Based on client interviews, 3 out of 5 clients reported that they saw bed bugs and rodents in the facility recently. It was learned there was no routine treatment service been initiated to properly to ensure preventative on-going measures.

Based on facility records and interviews with staff the information provided, it is clear that facility has bed bugs and rodents therefore the allegation was deemed SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

Exit interview was conducted and a copy of the report was provided upon exit.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
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-20240814022242
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KELLY ACACIO'S CARE HOME
FACILITY NUMBER: 347001602
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2024
Section Cited
CCR
80087(a)(1)
1
2
3
4
5
6
7
80087(a)(1). Buildings and Grounds. (a) The facility shall be clean, safe, sanitary and in good repair at all times...(1) The licensee shall take measures to keep the facility free of flies and other insects.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will ensure routine pest control service specific to bed bug prevention be initiated. Copy of updated service agreement reflecting said service to be submitted to LPA by POC due date.
8
9
10
11
12
13
14
Based on records reviewed and interviews, the facility had on-going issue with bed bugs and rodents. The licensee did not ensure a routine bed bug treatment service after an initial bed bug occurrence. This poses an immediate health, safety, and personal rights risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/14/2024 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20240814022242

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: DATE:
08/30/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:TIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not meeting the clients dietary needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/30/24, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to complete and delivery findings for a complaint investigation with the allegation above. LPA met with Licensee Kelly Acacio and discussed the conclusion for complaint and the findings.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on interviews and record reviews, there is not a preponderance of evidence to substantiate the allegation mentioned above. Based on client interviews, all five clients reported that their dietary needs were met. Facility staff stated that all meals were catered to client’s dietary needs.

As a result of the investigation, LPA finds the allegation above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted and a copy of the report was provided upon exit.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3