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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603404
Report Date: 04/25/2024
Date Signed: 04/25/2024 02:28:25 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/21/2024 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240221112607
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: 6DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Maura DemapanTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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9
Staff did not feed resident in care.
Lack of care resulting in resident sustaining wounds.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to deliver findings for the allegations listed above. LPA met with Staff, Maura Demapan, and explained the purpose of the visit.

On 2/29/24, LPA Chan conducted the initial visit to gather documents for Resident #1. Interviews were held with the administrator, 2 Staff, and 4 Residents. LPA interviewed the hospice agency nurse on a different date.

Allegation – Staff did not feed resident in care. It is alleged that Resident #1 (R1) has not eaten for over 3 days. The administrator and staff stated they offered R1 three meals a day but R1 sometimes refused to eat. They offer to cook any food R1 would like to eat, but R1 would also decline. When R1 does not eat, they would try to give a nutritional shake/drink to provide some nutrients. LPA interviewed the hospice nurse who was aware of R1 not eating for several days before hospitalization.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
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 2
Control Number 28-AS-20240221112607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ACACIA GUEST HOME
FACILITY NUMBER: 198603404
VISIT DATE: 04/25/2024
NARRATIVE
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Staff and the hospice nurse tried to encourage R1 to eat a little bit and/or to seek a higher level of care, however, R1 rejected any recommendation. They also indicated that R1 was not on any dietary restrictions and was simply refusing to eat. LPA interviewed 4 out of the 6 residents and 3 stated staff provided them with food and snacks. During the visit, LPA observed staff cooking and preparing meals for the residents. They provided R1 with the Ensure drink, as R1 did not want to eat the food made.

Allegation – Lack of care resulting in resident sustaining wounds. It is alleged that R1 developed wounds in the back, neck, groin, coccyx, abdominal folds, and legs. The administrator and staff interviewed indicated that R1 was admitted to the facility with wounds. They often try to reposition and change R1 but client was resistive to any staff help. They stated that a hospice agency nurse came out 3 times a week to treat the wounds. LPA interviewed the hospice agency nurse who confirmed R1 was being treated for these chronic wounds on the body. The nurse also indicated that R1 was non-compliant with the care being provided and repositioning. They have tried to educate R1 about the importance of treating the wounds and accepting the care, however, R1 would become angry. The hospice nurse also stated that R1 was very selective and had resisted any care being provided by certain nurses or staff. LPA interviewed 3 other residents who stated that staff are caring and assist them when needed. Based on the information gathered, R1 refused the care being provided and not that there was a lack of care from staff.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted with Staff Demapan. A copy of this report along with the appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2