Acacia Guest Home-Anaheim

Type of visit: POC

Licensing Program Analyst (LPA) Samer Haddadin arrived at the facility to conduct a Plan of Corrections (POC) visit. During the annual inspection conducted on October 17, 2025, the facility was issued three citations. During today’s visit, LPA verified that the following deficiencies had been corrected: · 87303(e)(6) · 87555(b)(26) · 87303(e)(5) Based on observations and verification, LPA determined that all previously issued Plans of Correction had been fully met. The deficiencies were cleared, and this report was reviewed with the Administrator. LPA provided the facility with official deficiency clearance letters at the conclusion of the visit.the state’s words, verbatim · CDSS document, Oct 21, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced Required – Annual Inspection at the facility. Upon arrival, LPA was greeted and granted entry by Care Staff Briyan Yosjaya, who was informed of the purpose of the visit. Administrator (AD) Jacklyn Concepcion arrived shortly thereafter. During the inspection, LPA, accompanied by facility staff, conducted a comprehensive tour of the interior and exterior of the facility, including common areas, residents’ bedrooms, kitchen, and garage. The facility is a single-story home consisting of four bedrooms and two bathrooms, with a detached garage. At the time of the visit, six residents were in care. LPA observed the kitchen area and confirmed that all appliances were operational. Knives and cleaning chemicals were properly secured in a locked kitchen cabinet, inaccessible to residents in care. Restroom #1 was found to be non-operational due to a leaking showerhead from the main pipe and a clogged bathtub drain. Additionally, the shower lacked a non-slip mat. Water temperature in both restrooms measured between 107.6 and 109.6 degrees Fahrenheit, which is within the regulatory range. LPA toured the exterior of the facility and observed a shaded seating area available for residents’ use. All emergency exits were found to be unobstructed and easily accessible. Upon inspection of food supplies, it was determined that the facility did not maintain the required two-day supply of perishable food and seven-day supply of non-perishable food as required by regulation. {***CONTINUE***} Additionally, the facility did not have an emergency supply of food and water available. Smoke detectors and carbon monoxide detectors were tested and found to be operational. The fire extinguisher was fully charged, with a purchase date of August 29, 2025. A review of two resident files and two staff files indicated that all required documentation was current. LPA observed that the facility’s posted PUB 475 was not in compliance with the required regulatory size of 20 x 26 inches. Review of the emergency drill log showed that the most recent drill was conducted on September 23, 2025. Based on observations made during today’s inspection, deficiencies are being cited in accordance with Title 22, Division 6 of the California Code of Regulations. This report was reviewed with the Administrator, and a copy of the report and appeal rights were provided to the Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Oct 17, 2025

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: POC

On 12/11/2024, LPA Dwayne Mason Jr arrived at the facility for the purpose of conducting a plan of corrections visit. On 10/28/2024, the facility was issued four citations as part of a complaint inspection and a case management visit. LPA reviewed documents and toured the facility. LPA observed all exit doors to be unobstructed. LPA observed all medication was removed from the facility refrigerator. LPA received documentation for an in-service training conducted on 10/31/2024. LPA received complete LIC9182 for the staff that were previously not associated to the facility. Based on today's visit, LPA determined the plans of correction previously issued were fulfilled. LPA cleared the deficiencies and reviewed this report with the Administrator. LPA also provided the facility with the deficiency clear letters.the state’s words, verbatim · CDSS document, Dec 11, 2024

Type of visit: Required - 1 Year

LPA toured the inside and outside of facility with (AD) and observed the following: The facility is a 4-bedroom, 2-bathroom, 1-story house with detached garage that is being used for storage. Resident Bedrooms: the 3 resident bedrooms are spacious and have all required furniture per regulations: Lights, chairs, linens, and storage for each resident bedroom. LPA found a pair of scissors, Skintegrity Spray for wounds and Clorox disinfectant wet napkins in one of the resident’s rooms. AD immediately removed and locked the items. The fourth bedroom is for staff and also had all required elements per regulation. LPA toured the kitchen and observed grease and left over oil splashes on stove and around the oven; stove had five burners and only 4 worked due to grease and oil being stuck. AD tried to clean stove and was unable to make the burner work. 7 kitchen drawers were loose and not intact in place. LPA checked restroom one and observed chipped paint in the shower area. Shower had a glass door which had mold and mildew around the rim and edges of the door. LPA checked water temperature and it was tested between 109.9 and 110.9 Degree Fahrenheit. LPA checked Carbon Monoxide, Smoke Detectors and all tested operational. Fire Extinguisher was in the green, fully charged, and last checked on July 17th, 2024. LPA checked food sully and the facility had the 2 days perishable and 7 days nonperishable food supply per regulation. LPA toured the outside of the facility and observed a shaded area with chairs and space for residents’ activities and enjoyment. LPA found full bottle of Windex, and Clorox in a blue bucket and accessible to residents in care. During record review, LPA observed that fire drills are conducted monthly. Staff records showed all required documentation including valid CPR.(..CONTINUE 809C....) LPA checked three residents’ file and observed that 2 out of 3 residents had dementia and none had a recent physician report: Resident (R1) last physician report was 8/14/23 and R2 physician report was 06/08/2023. Based on the observation made during today’s visit, deficiencies are being citied today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to the AD.the state’s words, verbatim · CDSS document, Dec 5, 2024

Allegation investigated: Facility did not ensure that residents are treated with dignity and respect.

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 (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. (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.the state’s words, verbatim · CDSS document, Oct 28, 2024 · control 22-AS-20241007163745

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(23) · Plan of correction due date: Nov 11, 2024

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. Based on observations, the licensee did not comply with the section cited above due to uncovered breakfast sausage and vegetables being observed inthe state’s words, verbatim · CDSS document, Oct 28, 2024

Plan of correction: 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.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a Case Management visit for the purpose of issuing deficiencies observed. LPA met with Caregivers Briyan Yosjaya and Brandy Guinto. While at the facility, LPA reviewed the staff members associated at the facility. LPA observed a staff member working at the facility at the time of the visit was not associated to the facility. LPA verified the staff member is cleared to work in CCLD facilities, but the staff member was not associated to the facility. A citation is being issued. While at the facility, LPA observed unlocked medication in the facility refrigerator. LPA determined the medication was accessible to residents in care. A citation is being issued. While at the facility, LPA observed two doors blocking emergency exits from the facility. LPA noted doors were not blocked in a way that prevents any resident from accessing the rest of the facility. A citation is being issued.the state’s words, verbatim · CDSS document, Oct 28, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 81019(e)(3) · Plan of correction due date: Nov 4, 2024

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 81019(f); This requirement is not met as evidenced by Based on a record review, the licensee did not comply with the section cited above as one out of two staff members present at the facility were not associated to the facility. This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 28, 2024

Plan of correction: Administrator stated they will associate all facility staff to the facility by the assigned POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(d)(6) · Plan of correction due date: Nov 4, 2024

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based on observations, two doors leading from resident rooms to outside the facility were observed to be obstructed by a bed frame and box spring in one room. The other room's door was blocked by a small dresser.the state’s words, verbatim · CDSS document, Oct 28, 2024

Plan of correction: Facility staff stated they will unobstruct both doors by the assigned POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Oct 29, 2024

(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. Based on observations, the Licensee did not comply with the section cited above due to medication being stored in the refrigerator without being locked.the state’s words, verbatim · CDSS document, Oct 28, 2024

Plan of correction: Administrator stated they will move medication to another refrigerator in a room with a lock or that they would purchase a lock box in order to safely store medication. AD stated they will notify LPA upon completion of plan.

Type of visit: Case Management - Deficiencies

On 10/17/2024, LPA Dwayne Mason Jr arrived at the facility for the purpose of conducting a case management visit for deficiencies. LPA was greeted and granted entry by facility staff. LPA met with Administrator (AD) Jacklyn Concepcion and explained the purpose for the visit. LPA reviewed Guardian and the Licensing Information System. Based on record review, LPA observed the two staff members working at the facility at the time of the inspection are not associated to the facility. LPA noted both staff members have obtained their criminal record clearance, but are not associated to the Acacia Guest Home-Anaheim facility. Based on today's inspection, one deficiency is being issued. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 17, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 81019(e)(3) · Plan of correction due date: Oct 24, 2024

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 81019(f); This requirement is not met as evidenced by Based on a record review, the licensee did not comply with the section cited above as two out of two staff members present at the facility were not associated to the facility. This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 17, 2024

Plan of correction: Administrator stated they will associate all facility staff to the facility by the assigned POC due date.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Staff #1 (S1) Zepta Tamba, discussed the purpose of the inspection, and toured the facility. Applicant (AP) Jacklyn Peng L Concepcion arrived during the inspection. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 07/13/2023. This is a change of ownership with persons in care. During the inspection, LPA and AP observed the following: Structure: facility is a 4-bedroom, 2-bathroom, 1-story house with detached garage that is being used for storage. Facility telephone number is (714) 671-8329. Resident Bedrooms: the 3 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Lights, chairs, linens, and storage for each resident bedroom inspected. Staff Bedrooms: the 1 staff bedroom is spacious and will easily accommodate the staff’s furnishings. Bathrooms: were clean, faucets and toilets were operational. Water temperature: tested at 109 degrees F in the resident bathroom. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: 2 days perishable and 7 days nonperishable food supply reviewed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen drawer. Toxins: observed locked in the kitchen and garage. Medication cabinet is locked. First-Aid Kit & Activity Supplies: observed and available. Resident & Staff Files: LPA reviewed 3 resident files and 1 staff file. Fire clearance was approved by Anaheim Fire Department on 09/08/2023. Backyard exit gate is operational and unlocked. Backyard has shaded area for outdoor activities and sufficient seating for residents. Component III was completed with AP during today’s inspection. Facility is currently operating under the liability insurance of current facility ANGEL ROSE RESIDENCE (306005228). AP will switch liability insurance to new facility once the application is approved. During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AP was informed today that the facility is ready for licensure and final approval will be processed by the CAB supervisor in Sacramento. An exit interview was conducted and a copy of this report was discussed with and provided to AP.the state’s words, verbatim · CDSS document, Dec 19, 2023

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 3 Interview Method: Telephone interview On 2/11/2023, applicant/administrator participated in COMP II. Identification of the applicant / administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant / administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Dec 11, 2023