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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603404
Report Date: 09/12/2024
Date Signed: 09/12/2024 04:48:09 PM

Document Has Been Signed on 09/12/2024 04:48 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:
09/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:35 PM
MET WITH:Francesca Olivia, StaffTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a follow up case management visit on the incident reported to licensing on 8/1/24. LPA arrived unannounced and met with Staff, Francesca Olivia. LPA spoke to administrator, Jacklyn Concepcion, via telephone to explain the reason for the visit.

On 8/8/24, LPA Chan conducted a visit due to an incident report submitted to LPA on 8/1/24 alleging that a staff member was inappropriately touching Resident #1 (R1). LPA conducted a health and safety check, interviewed 2 staff and 2 residents. Alleged staff denied inappropriately touching R1.
On 9/12/24, LPA interviewed Resident #1 via telephone who confirmed the allegation. LPA also interviewed R1's responsible party. Per the administrator, the police was informed of the incident and provided the report number.

Based on record review and interviews, there is no witness to testify to this claim. Therefore, there is insufficient evidence to prove the allegation at this time.
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: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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