Acacia Creek - Union City

Type of visit: Required - 1 Year

On today’s date at around 9:00 am, Licensing Program Analysts (LPAs) K. Nguyen and P. Manalo arrived unannounced to conduct an annual required inspection and met with Executive Director (ED) Julie Mammad. LPAs explained the purpose of the visit to the Executive Director. The facility has a main building with 5 floors and 4 cottages. The resident apartments were located on the first 4 floors of the main building and 4 cottages. The facility consists of a dining room, a bar, a game room, a boardroom, an art room, a multipurpose room, a library room, swimming pool, beauty salon, etc., all around the facility LPAs toured the facility with the Wellness Manager and inspected 6 rooms. The facility was observed to be clean and odor-free. The ED states that residents have pendants or use their telephones if they need assistance. Out of 184 residents, all are in assisted living. Multiple fire extinguishers were observed to be full and last serviced on 1/21/26. The last fire alarm inspection was conducted on 8/18/25. The fire drill was last conducted on 01/15/2026. Liability insurance is effective from 04/01/2026 to 04/01/2027. LPAs reviewed 6 staff files; 6 out of 6 staff have health clearance on their files. LPAs reviewed 7 residents’ files. The facility will submit an updated Emergency Disaster Plan (LIC610E) by 05/16/2026. THE FOLLOWING DEFICIENCY WAS OBSERVED DURING VISIT: At 10:23 AM, LPAs observed moldy tangerines in the kitchen walk-in fridge. The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiency by POC date may result in additional Civil Penalties. Exit interview conducted with Executive Director. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, May 6, 2026

Allegation investigated: Staff are keeping resident against their will.

*****THIS IS AN AMENDED REPORT FROM VISIT 05/22/2025***** On 05/22/2025 at around 10:00 am, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a complaint visit. LPA met with Wellness Manager, Viarmina Paje-Forsythe (Mina), and explained the purpose of the visit. LPA received via text from Executive Director Sandra Simon, for Mina to sign the report. Allegation: Staff are keeping resident against their will - UNFOUNDED During the course of the investigation, LPA K. Nguyen reviewed the resident roster from 2017- May 22, 2025. LPA conducted an interview with S1, S1 stated R1 never resided at the facility. A review of rosters reveals that the individuals involved in the incident are not residing at this facility; therefore, the above allegation is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiency observed or cited during this visit. An exit interview was conducted, and a copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, May 22, 2025 · control 15-AS-20250516101416

Allegation investigated: Staff did not refund the entrance fee as required by the continuing care contract

On 04/16/2025 at around 1 p.m Licensing Program Analysts (LPAs) K. Nguyen and P. Manalo arrived at facility unannounced to deliver findings for the complaint investigation related to the above listed allegation. LPAs met with Executive Director, Sandra Simon and explained the purpose of the visit. During the course of this investigation, the Department reviewed Acacia Creek Residence and Care Agreements, a California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities, an Assignment of Benefits Agreement form, Emergency Contact documentation, Pre-Admission Questionnaire, Physician’s Report, Mini-Mental State Examination report, entrance fee check copies, deposit check copies, bank account statements, Entrance Fee Refund Letter, refund checks, Deposit Worksheets and refund check calculation documents. ***Report Continued on LIC 9099c*** Unfounded The investigation revealed that Resident 1 (R1) entered into an agreement for residency at the community in June of 2016 and occupied a residential living unit for independent living until July of 2017 when he required a higher level of care. In July of 2017, R1 entered a skilled nursing facility affiliated with the community and remained there through the end of life until, March of 2019. To enter the community and receive the benefits of a continuum of care, R1 paid an entrance fee that is refundable based on a 36 month amortization. The beneficiaries to R1’s estate claim that the entrance fee should have been amortized based on the time frame beginning from entering into the agreement through entering into the skilled nursing facility, however the amortization was based on the date of death. The Residence and Care Agreement, document number 1243823.17, was approved by the Department for use. It states under Section VI – Termination, subsection E Refund to Resident it states that “Any refund paid under this Section VI.E.1 shall be made within fourteen (14) days after all of the following events occur: (1) you or your estate makes your Apartment available to Acacia in its original clean condition ( excluding normal wear and tear); (2) if applicable, you vacate any facility operated by Acacia Creek Union City (ACUC) or Masonic Homes of California (MHC) pursuant to this Agreement; and (3) you or your estate executes a document releasing Acacia from any and all duties and obligations under this Agreement.” In this case, R1, the subject of the complaint entered into a skilled nursing facility operated by MHC and therefore would not be entitled to refund. The allegation of “Staff did not refund the entrance fee as required by the continuing care contract” is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was given to Executive Director.the state’s words, verbatim · CDSS document, Apr 16, 2025 · control 15-AS-20250310213049

Type of visit: Required - 1 Year

On today’s date at around 9:30am, Licensing Program Analysts (LPAs) K. Nguyen and P. Manalo arrived unannounced to conduct annual required inspection and met with Executive Director, Sandra Simon. LPAs explained to Executive Director purpose of the visit. The facility has a main building consists of 5 floors and 4 cottages. The resident apartments were located on the first 4 floors of the main building and 4 cottages. The facility consists of dining room, bar, game room and board room, art room, multipurpose room, library room, etc. all around the facility LPAs toured facility with Wellness Manager and inspected 6 rooms. The facility has a swimming pool and beauty salon that were locked and enclosed. Executive Director states that there is no lifeguard on duty. However, there are cameras installed in the area. The facility was observed to be clean and odor free. Administrator states that residents have pendants or use their telephone, if they need assistance. Out of 171 residents, all are in the assisted living. There was multiple fire extinguishers observed that appear full and were last serviced on 01/10/2025. The last fire alarm inspection was conducted on 02/19/2025. The fire drill was last conducted on 02/19/2025. The liability insurance is effective 04/01/2025 to 04/01/2026. LPAs reviewed 6 staff files, 6 out of 6 staffs have health clearance on files. LPAs reviewed 10 residents’ files. No deficiencies were observed in the areas that were evaluated. No citations were issued during today’s inspection. Exit interview conducted and a copy of this report provided to Executive Director.the state’s words, verbatim · CDSS document, Apr 16, 2025

Type of visit: Case Management - Other

On 03/19/2025 at 2:30 PM, Licensing Program Analysts (LPAs) K. Nguyen and P.Manalo conducted an unannounced Case Management Visit related to the previous complaint 15-AS-20241204123458. LPAs met with Vilarmina Paje-Forsythe, Wellness Manager, and explained the purpose of the visit. Executive Director was unavailable during the visit and gave authorization on the phone for staff to sign the report. LPAs reviewed Resident 1’s (R1) record shows facility did not have proper documentation of the resident’s care plan. Care Plan did not indicate what services was needed for the residents to have 1:1 care. Plan of correction is for the facility to review all resident’s care plan and physician’s report to indicate what services the residents do or do not need. No deficiency cited during the visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 19, 2025

Allegation investigated: Resident sustained injuries due to lack of care and supervision from staff Staff did not ensure that resident's toileting needs were met

*****THIS IS AN AMENDED REPORT FROM VISIT 3/7/25***** On 3/25/2025 at 1p.m. Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced visit to deliver the findings for the above complaint allegation. LPA met with Sandra C. Simon, Excutive Director explained the purpose of the visit. Allegation: Resident sustained injuries due to lack of care and supervision from staff: Unsubstantiated On 3/07/2025, The department reviewed record of R1 including medical record, discharge summary, report and progress notes indicated R1 was admitted to ER due to an unwitnessed fall on 11/26/24. R1 was in the hospital Report Continue on LIC9099... Unsubstantiated *****THIS IS AN AMENDED REPORT FROM VISIT 3/7/25***** On 3/7/2025, the department interviewed staff (S1), resident (R1), and owner of assisting hands home care agency (OSA). The department reviewed staff roster with contact numbers, physician's report, care plan, emergency information, progress notes, Unusual Incident/ Injury report (UIR), and resident dinner check off list to for date confirmation. R1 physician report shows R1 is independent with only need of toileting assist. R1 needs and service plan shows that R1 is not a fall risk and doesn’t need staff to come unless R1 press the pendant. S1 confirmed that S1 only attended to R1 only when R1 press the pendant. This was confirmed with R1 during the interview regarding to the facility care staff attending to R1 only when R1 press the pendant that’s when facility care staff comes. R1 stated the reason why R1 hired a private caretaker due companionship and for R1 personal needs such as clean R1 apartment daily, because the facility only cleans the apartment once a week. R1 want private caretaker to wash dishes daily, laundry, take out the trash, ect. R1 did not sustained any major injury, but R1 sustained minor cut on R1 eyebrow. Allegation: Staff did not ensure that resident's toileting needs were met On 3/7/2025, the department reviewed R1 care plan, and interviewed resident (R1), showed that R1 toileting needs were met. R1 care plan shows that R1 is not a fall risk and only press the pendant when R1 needs assistance from facility care staff. R1 stated “I have no complaint of any care staff because when I need assistance with toileting, they provided to me”. R1 stated staffs are very friendly and helpful. 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. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 7, 2025 · control 15-AS-20241204123458

Type of visit: Case Management - Health Checks

On 12/05/24 at 2:15PM, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced Health and Safety check due to the department receiving a priority 2 complaint. LPA explained the purpose of the visit with Executive Director, Sandra Simon. During the health and safety check, LPA observed facility is preparing for the tree light event. LPA toured facility with Executive Director, including but not limited to bedrooms, kitchen, dining rooms, activities rooms, bathroom, outdoor garden and common areas. LPA observed residents comfortable in their surroundings, relaxing in their apartment, and common areas with family and friends. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 5, 2024

Type of visit: Required - 1 Year

At around 9:30am, Licensing Program Analyst (LPA) Kelly Nguyen arrived unannounced to conduct annual required inspection and met with Administrator Chuck Major. LPA explained to Administrator purpose of the visit. The facility has a main building consists of 5 floors and 4 cottages. The resident apartments were located on the first 4 floors of the main building and 4 cottages. Dining room, bar, game room and board room are all located on the 5th floor. LPA with Administrator inspected 5 rooms. The facility has a swimming pool and spa that were locked and enclosed. Administrator states that there is no lifeguard on duty. However, there are cameras installed in the area. The facility was observed to be clean and odor free. Administrator states that residents have pendants or use their telephone, if they need assistance. Out of 159 residents, 6 are in the assisted living. There were multiple fire extinguishers observed that appear full and were last serviced on 01/17/2024. The last fire alarm inspection was conducted on 4/26/2024. There was sufficient supply of perishable and non-perishable foods observed. Freezer temperature was observed at -2- and 0-degrees Fahrenheit. Refrigerator temperature measured at 37.5- and 35.4-degrees Fahrenheit. First aid kit was observed complete. Vehicle insurance and registration were verified as current. continuation on Lic 809C LPA reviewed 6 staff files 6 out of 6 staffs have health clearance on files. LPA reviewed 6 residents files. No deficiencies were observed in the areas that were evaluated. No citations were issued during today’s inspection. Exit interview conducted and a copy of this report provided via email to Executive Director.the state’s words, verbatim · CDSS document, May 29, 2024