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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604552
Report Date: 11/29/2023
Date Signed: 11/29/2023 03:52:33 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
10/31/2023 and conducted by Evaluator Amy Domingo
COMPLAINT CONTROL NUMBER: 08-AS-20231031094440
FACILITY NAME:ACORN OAKS MANOR IIFACILITY NUMBER:
374604552
ADMINISTRATOR:LIMPIN, ALEXANDERFACILITY TYPE:
740
ADDRESS:6217 ACORN STTELEPHONE:
(619) 777-9674
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY:14CENSUS: 12DATE:
11/29/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jamila Hallak House ManagerTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
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9
Licensee did not provide refund as required.
INVESTIGATION FINDINGS:
1
2
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5
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7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the finding in the above mention complaint allegation. LPA Domingo identified herself and discussed the purpose of the visit with House Manager Jamila Hallak.

During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff, residents and outside sources.

It was alleged that Resident 1 (R1) (See LIC811 Confidential Names list), did not receive a refund as required. LPA Domingo conducted an interview with outside source 1 (OS1) and OS1 verified that the refund was received and the facility did provide a refund as required. Staff 1 (S1) was interviewed and S1 also provided documentation that the facility did provide a refund as required.

[Continue on LIC9099C]

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy DomingoTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
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 2
Control Number 08-AS-20231031094440
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ACORN OAKS MANOR II
FACILITY NUMBER: 374604552
VISIT DATE: 11/29/2023
NARRATIVE
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[Continued from LIC9099]

Based on LPA's interview with outside sources and records reviewed there is not a preponderance of evidence to prove alleged violation did not occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with the House Manager, to whom a copy of this report, and the Licensee Appeal Rights (LIC 9058 03/22) were provided.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy DomingoTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2