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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006383
Report Date: 10/28/2024
Date Signed: 10/28/2024 02:36:03 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2024 and conducted by Evaluator Dwayne L Mason
COMPLAINT CONTROL NUMBER: 22-AS-20241007163745
FACILITY NAME:ACACIA GUEST HOME-ANAHEIMFACILITY NUMBER:
306006383
ADMINISTRATOR:CONCEPCION, JACKLYN PENG LFACILITY TYPE:
740
ADDRESS:1516 W LA PALMA AVENUETELEPHONE:
(626) 541-5921
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:6CENSUS: 5DATE:
10/28/2024
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Jacklyn Concepcion - AdministratorTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Facility did not ensure that residents are treated with dignity and respect.
INVESTIGATION FINDINGS:
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This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is
being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned
above. LPA arrived at the facility and was greeted by facility staff. LPA met with Jacklyn Concepcion, Administrator via phone call and explained the nature of the inspection.

The department received a complaint on 10/07/2024 stating Facility did not ensure that residents are treated with dignity and respect. During the investigation, the department interviewed the Administrator (AD), staff and residents in care.

(continued on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
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 5
Control Number 22-AS-20241007163745
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ACACIA GUEST HOME-ANAHEIM
FACILITY NUMBER: 306006383
VISIT DATE: 10/28/2024
NARRATIVE
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(continued from LIC9099)

On 10/17/2024 LPA conducted a visit to the facility. LPA obtained copies of the Personnel Report dated 9/1/2024, Resident Roster dated 4/15/2024 and copies of Resident files. LPA conducted interviews with five out of six residents in care. Out of five residents interviewed, four stated that they are treated with dignity and respect. Based on staff interviews, three out of three staff stated they treat residents with dignity and respect.
Based on the investigation, LPA was unable to determine if residents are or are not treated with dignity and respect.

Based on interviews conducted and records reviewed there is insufficient evidence to support the
allegation(s). Although the allegation(s) may have happened or is valid; there is not a
preponderance of evidence to prove that the alleged violation(s) did or did not occur, therefore
the allegation is UNSUBSTANTIATED.

An exit interview was conducted, and this report was reviewed with Jacklyn Concepcion, Administrator (AD). A copy of this LIC-9099 was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2024 and conducted by Evaluator Dwayne L Mason
COMPLAINT CONTROL NUMBER: 22-AS-20241007163745

FACILITY NAME:ACACIA GUEST HOME-ANAHEIMFACILITY NUMBER:
306006383
ADMINISTRATOR:CONCEPCION, JACKLYN PENG LFACILITY TYPE:
740
ADDRESS:1516 W LA PALMA AVENUETELEPHONE:
(626) 541-5921
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:6CENSUS: 6DATE:
10/28/2024
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Jacklyn ConcepcionTIME COMPLETED:
02:40 PM
ALLEGATION(S):
1
2
3
4
5
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9
Facility did not ensure food is of good quality.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is
being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned
above. LPA arrived at the facility and was greeted by facility staff. LPA met with Jacklyn Concepcion, Administrator via phone call and explained the nature of the inspection.

The department received a complaint on 10/07/2024 stating facility did not ensure food is of good quality. During the investigation, the department interviewed the Administrator (AD), staff and residents in care.

(continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20241007163745
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ACACIA GUEST HOME-ANAHEIM
FACILITY NUMBER: 306006383
VISIT DATE: 10/28/2024
NARRATIVE
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(continued from LIC9099)

On 10/17/2024 LPA conducted a visit to the facility. LPA obtained copies of the Personnel Report dated 9/1/2024, Resident Roster dated 4/15/2024 and copies of Resident files. LPA conducted interviews with five out of six residents in care. Out of five residents interviewed, four stated that the food served is acceptable in quality. Based on staff interviews, three out of three staff stated the food is of good quality.

On 10/28/2024, LPA observed the facility refrigerator/freezer. LPA observed uncovered breakfast sausage and vegetables in the freezer and refrigerator. Title 22 Regulations 87555(b)(23) states the following "All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures." Based on observations, the facility did not comply with the citation stated above due to the aforementioned stored food items not being covered.

The preponderance of evidence standard has been met. The allegation of Facility did not enure that food is of good quality is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099, deficiency page and appeal rights were provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20241007163745
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ACACIA GUEST HOME-ANAHEIM
FACILITY NUMBER: 306006383
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/11/2024
Section Cited
CCR
87555(b)(23)
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87555(b)(23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.
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Administrator stated they will conduct an in-service training pertaining to food storage/handling/preparation. AD stated they will document topics covered, staff in attendance and date/time of training and send the documentation to the LPA via email by the POC due date.
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Based on observations, the licensee did not comply with the section cited above due to uncovered breakfast sausage and vegetables being observed in
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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.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5