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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603404
Report Date: 03/06/2026
Date Signed: 03/06/2026 05:53:55 PM

Document Has Been Signed on 03/06/2026 05:53 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
MONTEREY PARK ASC, 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:
03/06/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:52 AM
MET WITH:Jacklyn Peng Lee Concepcion - AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA was met by James Alfonso Loppies, Caregiver and explained the purpose of the visit. The administrator, Jacklyn Peng Lee Concepcion was called and arrived at 11:45am to assist LPA with the inspection. The facility is approved to serve residents age range 60 and over, (6) non ambulatory, of which (1) may be bedridden. Hospice waiver approved for (3) residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility is continuing to follow their Infection Control Plan. Administrator reviewed and updated the Infection Control plan annually. Staff are trained in the proper use of all required PPEs.


Operational Requirements: Plan of operation was reviewed. The facility accepts and retains residents with dementia. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 07/24/2026.
Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood which consists of (4) resident bedrooms, (2) staff bedrooms, (1) with en-suite bathroom, (1) communal bathroom, living room with fireplace, dining area with fireplace, kitchen, laundry area, attached garage, and backyard with shaded area with tables and chairs. There are currently (6) residents, 60 years and older residing in the facility, (2) are under hospice care and (1) bedridden. The interior and exterior physical plant was inspected. LPA observed both fireplaces to be uncovered, unsecured and accessible to residents. Resident bedrooms were toured. Each bedroom has a bed, linen, light, chair and sufficient closet space. There are (3) refrigerators/freezers, (2) in the kitchen/dining area and (1) near the laundry area. There are no working auditory devices in the exit points. The backyard was inspected and was observed to be disorganized with miscellaneous junk and toxic materials around the area. There are (2) fire extinguishers in the facility and one purchased in December 2025 was not mounted on the wall. Smoke detectors and carbon monoxide detectors were tested and operable. The facility is not following the existing sketch as one of the designated room for the resident has been changed to a staff room. There are cameras with audio at the facility. The hot water temperature was measured between the required range of 105-120 degrees F.*****REPORT CONTINUED ON LIC809-C*****
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ACACIA GUEST HOME
FACILITY NUMBER: 198603404
VISIT DATE: 03/06/2026
NARRATIVE
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Staffing: A total of (3) caregivers plus the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 have criminal background clearance, fingerprint cleared and associated to the facility. However, staff files are incomplete, such as personnel records and none of them have completed the first aid/CPR training.
Personnel Records-Training: Four (4) staff files were reviewed for criminal background clearance, training and have health/TB screenings. Administrator has completed the required administrator courses, no certificate yet but it is valid through 07/21/2026.
Resident Rights-Information: Resident personal rights are posted. Facility provides internet services to all residents and have access to the facility phone. Administrator provides ongoing training for staff.
Planned Activities: Information regarding Dementia is part of training for direct care staff and is included in the Plan of Operation. The facility provides sufficient space to accommodate both indoor and outdoor activities.
Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Pesticides and cleaning supplies are kept away from the food preparation areas. (2) residents require modified diet.
Incidental Medical Services: Residents' medications were reviewed during the visit. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are stored in a medical cart and inaccessible to residents. LPA observed errors in administering and documenting medications to the residents.
Resident Records-Incident Reports: (6) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, Medical Consent, Medication Records. However, some required files are missing.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. Emergency/disaster drills are conducted quarterly, recent one was conducted on 02/06/2026.
Residents with SHN: (2) residents are under hospice care. Physicians order for bed rails for the residents were on file. There are no residents utilizing oxygen at this time.

Deficiencies cited. Technical Advisories issued. Exit interview and a copy of this report was provided to the Administrator, Jacklyn Peng Lee Concepcion.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2026
LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 03/06/2026 05:53 PM - It Cannot Be Edited


Created By: Bennette Pena On 03/06/2026 at 03:03 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: 03/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that there are toxins, garden materials in the backyard that were exposed and accessible to residents. Additionally, a gallon of bleach was out and used as door stopper in the kitchen which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 03/07/2026
Plan of Correction
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Administrator will re-train staff about locking toxins, poisonous substances in a locked storage inaccessible to residents. In service training log shall be sent to CCL/LPA by POC due date.
Type A
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in that (3) out of (4) staff did not have a complete Personnel record on file which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 03/09/2026
Plan of Correction
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Administrator to send completed personnel records of all (3) staff members to CCL/LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/06/2026 05:53 PM - It Cannot Be Edited


Created By: Bennette Pena On 03/06/2026 at 03:03 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: 03/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and review of documentation, R1-R5's Medication Administration Record (MAR) for March 2026 is inaccurate. MAR for March 2026 shows that staff initialed the medication log for March 6, 2026 - March 7, 2026 even if the medications were not administered yet. Additionally, some of the residents morning medications were administered for March 6, 2026 but not properly initialed/documented on MAR which posed an immediate health and safety risk to residents in care.
POC Due Date: 03/09/2026
Plan of Correction
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Administrator shall ensure that the Medication Administration Records (MARs) are accurate for all residents. Administrator agreed to submit a plan of correction to avoid improper documentation of Medication Administration Record (MAR) and prevent medication errors.Additionally, all facility staff in charge of medication management shall be re-trained on Medication Management & proper documentation. A copy of the in-service training form along with topics discussed and signatures of staff present will be submitted to CCL/LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/06/2026 05:53 PM - It Cannot Be Edited


Created By: Bennette Pena On 03/06/2026 at 03:03 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: 03/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(f)
Maintenance and Operation
(f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the backyard was observed to be disorganized with miscellaneous junk and toxic materials around the area which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 03/20/2026
Plan of Correction
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Administrator clean up the backyard and store toxic materials in a locked cabinet. Administrator to send photos of the cleared backyard to CCL/LPA by POC due date.
Type B
Section Cited
CCR
87303(i)(1)(B)
Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that there are no working auditory devices in the exit points which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 03/20/2026
Plan of Correction
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Administrator to install buzzers/auditory devices on all exit doors/points and send photos as proof to CCL/LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2026


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 03/06/2026 05:53 PM - It Cannot Be Edited


Created By: Bennette Pena On 03/06/2026 at 03:03 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: 03/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that (3) out of (4) staff working in the facility do not have cardiopulmonary resuscitation (CPR) training and first aid training which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 03/20/2026
Plan of Correction
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Administrator will send proof of enrollment for first aid/CPR training for (1) day shift staff and (1) night shift staff to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2026


LIC809 (FAS) - (06/04)
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