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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603404
Report Date: 04/25/2024
Date Signed: 04/25/2024 02:30:58 PM

Document Has Been Signed on 04/25/2024 02:30 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ACACIA GUEST HOMEFACILITY NUMBER:
198603404
ADMINISTRATOR/
DIRECTOR:		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
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Maura Demapan, StaffTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit on 4/25/24. LPA met with Staff, Maura Demapan and explained the purpose of the visit.

During the visit, LPA observed Resident #1 (R1) residing in the room to the right of the entrance. According to the facility sketch, the space was indicated as the dining room. The room does not have a door and the facility uses a fabric curtain to provide privacy to the resident. Staff stated R1 was moved to the area a few months ago. LPA issued a deficiency for resident residing in a common area. There are a total of 6 residents observed at the home.

An exit interview was held. The plan of correction was discussed with the administrator via telephone. A copy of this report along with appeal rights were emailed to the administrator per request.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR 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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/25/2024 02:30 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 04/25/2024 at 02:00 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: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2024
Section Cited
CCR
87307(a)(2)(B)

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87307 Personal Accommodations and Services (a) Living accommodations and grounds...(2) Resident bedrooms shall be provided...(B) No room commonly used for other purposes shall be used as a sleeping room for any resident.
This requirement is not met as evidenced by:
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The licensee shall appropriately place Resident #1 in a resident room as indicated on the facility sketch. The licensee shall submit a statement acknowledging this regulation has been read.
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Based on observation, Resident #1 was moved to a dining room area per the facility sketch which poses a potential personal rights risk to residents in care.
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The licensee will also provide photos of the resident #1's belongings removed from the common area and into an assigned room. This POC is due by 5/2/24.

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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:Tony Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024


LIC809 (FAS) - (06/04)
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