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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603404
Report Date: 08/08/2024
Date Signed: 08/08/2024 05:45:13 PM

Document Has Been Signed on 08/08/2024 05:45 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:
08/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:35 PM
MET WITH:Efren Maralit, CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit due to an incident that was reported by the facility. LPA arrived unannounced and met with Staff, Efren Maralit. The purpose of the visit was explained.

The incident report submitted to LPA on 8/1/24 alleged that a staff member was inappropriately touching Resident #1. LPA conducted a health and safety check, interviewed 2 staff and 2 residents. LPA requested documents pertaining to Resident #1 to be emailed. LPA will continue to gather information on this incident.

No deficiencies were issued today. A copy of this report was given to the staff.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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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