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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603404
Report Date: 11/14/2024
Date Signed: 11/14/2024 07:45:47 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
11/07/2024 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241107150127
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:
11/14/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Brandy Guinto, CaregiverTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff do not ensure residents are provided with a comfortable environment.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegation listed above. LPA arrived unannounced and met with Staff, Brandy Guinto. The purpose of the visit was explained. Administrator, Jacklyn Concepcion, arrived shortly after.

LPA obtained copies of the resident and staff rosters, reviewed Resident #1’s file, and toured the facility. Interviews were held with the administrator, 2 staff, and 2 residents.

For allegation, staff do not ensure residents are provided with a comfortable environment. It is alleged that Resident #1 (R1) is yelling all day long and nothing was done by the owner. LPA interviewed the administrator, staff, and residents. The administrator stated that when it was brought to her attention, she immediately intervened and tried to figure out the cause. She contacted the family member to speak with the resident and the doctor for recommendations to reduce the behavior. She stated the doctor had adjusted the medication several times for R1 since admitted in September 2024 because of the behavior.
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: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
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-20241107150127
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: 11/14/2024
NARRATIVE
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Staff interviewed stated they are trying their best to provide a comfortable environment for residents. When R1 displays the behaviors, staff try to redirect R1 which does not seem to work. Staff stated R1 is given the PRN which was prescribed by the doctor and that helps reduce the behavior a little. Staff also had been communicating with the hospice nurse regarding the verbal behavior. LPA interviewed residents who stated R1 had been screaming or talking loudly some nights which interrupts their sleep. Based on information gathered, staff have been addressing R1’s behavior with the doctor and nurses and trying to reduce the frequency of its occurrence.

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



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

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2