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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601302
Report Date: 03/19/2025
Date Signed: 03/19/2025 03:43:50 PM

Document Has Been Signed on 03/19/2025 03:43 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ACACIA CREEK - UNION CITYFACILITY NUMBER:
015601302
ADMINISTRATOR/
DIRECTOR:		CHUCK MAJORFACILITY TYPE:
741
ADDRESS:34400 MISSION BLVD.TELEPHONE:
(510) 441-3700
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 376CENSUS: 177DATE:
03/19/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Vilarmina Paje-Forsythe, Wellness ManagerTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 03/19/2025 at 2:30 PM, Licensing Program Analysts (LPAs) K. Nguyen and P.Manalo conducted an unannounced Case Management Visit related to the previous complaint 15-AS-20241204123458. LPAs met with Vilarmina Paje-Forsythe, Wellness Manager, and explained the purpose of the visit. Executive Director was unavailable during the visit and gave authorization on the phone for staff to sign the report.

LPAs reviewed Resident 1’s (R1) record shows facility did not have proper documentation of the resident’s care plan. Care Plan did not indicate what services was needed for the residents to have 1:1 care. Plan of correction is for the facility to review all resident’s care plan and physician’s report to indicate what services the residents do or do not need.

No deficiency cited during the visit. Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1