374603837-5-13-2021-08-AS-LTEZ-D7JW58-20240726165843

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603837
Report Date: 05/13/2021
Date Signed: 05/13/2021 08:24:41 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/13/2021 and conducted by Evaluator Rebecca Hedgecock

COMPLAINT CONTROL NUMBER: 08-AS-20210513124053

FACILITY NAME:	ACORN OAKS MANOR I		FACILITY NUMBER:	374603837
ADMINISTRATOR:	CHEN, HATTIE		FACILITY TYPE:	740
ADDRESS:	6207 ACORN ST		TELEPHONE:	(619) 265-8416
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92115
CAPACITY:	6	CENSUS: 5	DATE:	05/13/2021
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Jamily Hallak, Med Tech		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Absence of Supervision

INVESTIGATION FINDINGS:

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Licensing Program Manager (LPM) Rebecca Hedgecock and Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Complaint Visit. LPM and LPA were granted entry into facility by Med Tech/Caregiver, Jamily Hallak. We discussed the purpose of today's visit.

LPM/LPA conducted a tour of the facility with Med Tech, Jamily Hallak and briefly interacted with residents in care. LPM/LPA observed three (3) residents in their bedroom and no staff present until Jamily entered the facility with LPM and LPA. At time of visit, two (2) residents were visiting their sister facility Acorn Oaks Manor II which is adjacent to Acorn Oaks Manor I. Interview revealed that staff stay primarily at their sister facility Acorn Oaks Manor II and will check in on residents anywhere from every 30 minutes to 2 hours. Residents do maintain call buttons that will alert staff in the adjunct facility of their need for assistance when staff are not present in the home.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Icela Estrada	TELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Rebecca Hedgecock	TELEPHONE: (619) 241-0535
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20210513124053

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ACORN OAKS MANOR I	FACILITY NUMBER: 374603837
	VISIT DATE: 05/13/2021

NARRATIVE

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The above allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. The deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D. Immediate civil penalties issued at today's visit.

LPM Hedgecock spoke to Licensee Hattie Chen and reviewed report findings, civil penalties and POC. An exit interview was conducted with Jamily Hallak and a copy of this report along with appeal rights (LIC 9058 01/16) and LIC 421, was provided via electronic mail to Hattie Chen. A read receipt will be requested as confirmation of receipt of documents.

SUPERVISOR'S NAME: Icela Estrada	TELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Rebecca Hedgecock	TELEPHONE: (619) 241-0535
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021

LIC9099 (FAS) - (06/04)

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Citations on this Visit Report are Under Appeal!

Control Number 08-AS-20210513124053

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ACORN OAKS MANOR I	FACILITY NUMBER: 374603837
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/13/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Under Appeal Type A 05/14/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	At time of visit, one (1) staff was immediately brought into the home to provide supervision for residents. Licensee to submit LIC 500 by POC date showing constant supervision in the home.
	8 9 10 11 12 13 14	Based on LPM/LPA observations and interview conducted, 3 out of 5 residents were left alone in home with no staff present. This posed an immediate safety risk to residents in care.	8 9 10 11 12 13 14	Immediate civil penalty of $500 is being accessed at today's visit. $100 a day penalty will be incurred until POC is corrected.
	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: Icela Estrada	TELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Rebecca Hedgecock	TELEPHONE: (619) 241-0535
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021

LIC9099 (FAS) - (06/04)

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