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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603404
Report Date: 03/25/2022
Date Signed: 03/25/2022 02:50:34 PM

Document Has Been Signed on 03/25/2022 02:50 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ACACIA GUEST HOMEFACILITY NUMBER:
198603404
ADMINISTRATOR:CONCEPCION, JACKLYN PENG LFACILITY TYPE:
740
ADDRESS:1847 ACACIA HILL ROADTELEPHONE:
(909) 895-7807
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: 5DATE:
03/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Caregiver, Jefren MaralitTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with caregiver, Jefren Maralit and explained the reason for the visit. Administrator was called and notified of the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed residents' medications and records, observed food supply, and reviewed staff records. The facility cares for elderly residents and is approved for 3 hospice residents. There are currently 3 residents on hospice.

All resident bedrooms were toured. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The resident bathrooms have the required grabs bars and non-skid mat. The hot water was 106.6 degrees which is within the required 105 - 120 degrees. Cleaning supplies are inaccessible to residents. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and seem to be operating properly. The common areas include the living room and dining area. These areas are clean and have the required furniture. There is a screening station at the entrance of the home which has PPEs and a thermometer to screen visitors. Staff document resident temperatures daily and require visitors to sign in. Facility currently has at least a 30-day supply of PPEs.

LPA reviewed 5 resident records to confirm emergency contact is updated and residents have health screenings on file. Resident #1 (R1) was admitted on 6/6/21 and did not have a physician's report on file. Resident #2 (R2) was admitted on 9/1/21 and did not have a physician's report on file. 2 staff records were reviewed to confirm health screenings, training and fingerprint clearances. LPA reviewed 5 residents' medications. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, the deficiencies observed during the visit are documented on the attached 9099D. Exit interview held. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/25/2022 02:50 PM - It Cannot Be Edited


Created By: Tony Vasallo On 03/25/2022 at 02:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ACACIA GUEST HOME
FACILITY NUMBER: 198603404

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(10)
Resident Records
(b) Each resident's record shall contain at least the following information: (10) Reports of the medical assessment specified in Section 87458 Medical Assessment, and of any special problems or precautions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above in 2 out of 5 resident records which poses a potential health, safety or personal rights risk to persons in care. Resident #1 (R1) was admitted on 6/6/21 and did not have a physician's report on file. Resident #2 (R2) was admitted on 9/1/21 and did not have a physician's report on file.
POC Due Date: 04/08/2022
Plan of Correction
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Facility will provide proof of recent physician's report for both residents. Proof is due by 4/8/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Tony Vasallo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022


LIC809 (FAS) - (06/04)
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