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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604755
Report Date: 11/22/2024
Date Signed: 11/22/2024 01:47:18 PM

Document Has Been Signed on 11/22/2024 01:47 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ACORN OAKS MANOR IVFACILITY NUMBER:
374604755
ADMINISTRATOR/
DIRECTOR:		WILLIAMS, MARIAFACILITY TYPE:
740
ADDRESS:6205 ACORN STTELEPHONE:
(619) 410-3002
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY: 6CENSUS: 2DATE:
11/22/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Jamily Hallak, House Manager
Maria Williams, LIcensee		TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Amy Rodgers and Angelica Boyles conducted an unannounced postlicensing visit to the facility today. The facility is located on a multi-use property which includes three other licensed facilities. LPAs entered common use ground and knocked on the facility’s door. LPAs entered the facility and after 10 minutes an adjacent licensed facility staff member, S1 came to greet LPAs. House manager Jamily Hallak arrived shortly after and explained that most visitors sign in at an adjacent licensed facility and then proceed to an occupied building. Licensee Maria Williams arrived later to discuss the postlicensing visit findings.

LPAs toured the facility in addition to conducting a general overall inspection, which included, but was not limited to, the following: facility physical plant, food service, medication management, records review, and facility administration.

The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, and meetings..

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. There were no toxic chemicals/poisons accessible to clients. Medications were labeled and stored in a locked area. No pools or bodies of water on the premises. Per staff, no firearms or ammunition are kept at the facility. Carbon monoxide detector, fire extinguisher, and facility telephone were present.

[CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Angelica Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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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Document Has Been Signed on 11/22/2024 01:47 PM - It Cannot Be Edited


Created By: Angelica Boyles On 11/22/2024 at 11:28 AM
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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ACORN OAKS MANOR IV
FACILITY NUMBER: 374604755

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(a)
Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 2 residents were left alone in home with no staff present. This posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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At time of visit, one (1) staff was immediately brought into the home to provide supervision for resident. Licensee to submit LIC 500 by POC date showing constant supervision in the home.
Immediate civil penalty of $500 is being accessed at today's visit. $100 a day penalty will be incured until POC is corrected.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Simon Jacob
LICENSING EVALUATOR NAME:Angelica Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024


LIC809 (FAS) - (06/04)
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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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ACORN OAKS MANOR IV
FACILITY NUMBER: 374604755
VISIT DATE: 11/22/2024
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[CONTINUED FROM LIC 809]

During today's visit, LPAs walked through the facility and interacted with the resident in care (R1). The other resident (R2) is currently at a skilled nursing facility. LPAs also conducted a file review for the residents. Staff interviews revealed that there is not staff assigned to the facility at all times nor is there a staff schedule reflecting staff being present at the facility. Interview with the licensee state staff from the sister facilities Acorn Oaks Manor I, II, and III check on residents. Interview with staff #3 (S3) state that the sister facilities Acorn Oaks Manor I, II, and III check on residents anywhere from every 20 minutes to 2 hours. Residents do maintain call buttons that will alert staff in the adjunct facility of their need of assistance when staff are not present in the home. However, LPA Rodgers conducted an interview with R1 in which he was unable to identify the location of his call button or that a call button was present.

A deficiency is being cited due to absence of supervision. The deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D. An immediate civil penalty in the amount of $500 issued at today's visit. LPAs spoke to Licensee Maria Williams and reviewed report, civil penalties and POC.

An exit interview was conducted with Licensee Maria Williams whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Angelica Boyles
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC809 (FAS) - (06/04)
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