Acacia Manor

Type of visit: Case Management - Other

On July 22, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced facility closure inspection. LPA met with Administrator, Luz Tan and explained the purpose of the visit. During the tour of the facility, LPA observed the kitchen, living room, dining room, bedrooms, outdoor and garage. LPA did not observe any residents and did not observe evidence of care and supervision In the home. CCLD will be proceeding with the closure as the licensee is no longer interested in maintaining a license. A forfeiture letter will be sent to licensee and the facility number 415600085 shall be closed. This report is reviewed, and discussed with the administrator/Licensee, and a copy is provided.the state’s words, verbatim · CDSS document, Jul 22, 2026

Type of visit: Required - 1 Year

On June 18, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with the administrator, Luzviminda Tan and LPA explains the purpose of today's visit. LPA toured the facility inside and out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, and backyard. The indoor and outdoor passageways were free of obstruction. The facility has 4 resident rooms and 4 bathrooms. Furniture and furnishings were observed to be sufficient. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas were observed clean and in operating condition. Showers were observed equipped with non-skid mats and grab bars. Comfortable temperature is maintained and lighting is sufficient for comfort. Central storage for medications, sharps and chemicals were observed to be locked and inaccessible to residents in care. Hot water temperature in the kitchen and bathroom were measured at 107 degrees Fahrenheit. Fire extinguishers were checked. A review of (2) resident files was conducted and noted on the LIC 858. A review of (1) staff files was conducted and noted on the LIC 859. LPA requested for a copy of the Liability Insurance and a copy of the Administrator Certification to be submitted to CCL by 6/23/2025. No deficiency is cited today. This report is reviewed and discussed with the administrator; a copy is provided.the state’s words, verbatim · CDSS document, Jun 18, 2025

Type of visit: Required - 1 Year

On May 30, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregiver, Evelyn Balaga and explained the purpose of the visit. The administrator, Luzviminda Tan arrived shortly thereafter and assisted with the inspection. LPA toured the facility inside and out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, and backyard. The indoor and outdoor passageways were free of obstruction. The facility has 4 resident rooms and 4 bathrooms. Furniture and furnishings were observed to be sufficient. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas were observed clean and in operating condition. Showers were observed equipped with non-skid mats and grab bars. Comfortable temperature is maintained and lighting is sufficient for comfort. Central storage for medications, sharps and chemicals were observed to be locked and inaccessible to residents in care. Hot water temperature in the kitchen and bathroom were measured at 107-110 degrees Fahrenheit. Fire extinguishers were checked and last inspected on 8/25/2022. A review of (1) resident files was conducted and noted on the LIC 858. A review of (1) staff files was conducted and noted on the LIC 859. No deficiency is cited today. This report is reviewed and discussed with the administrator; a copy is provided.the state’s words, verbatim · CDSS document, May 30, 2024

Allegation investigated: Facility does not have a substitute administrator. Staff are mishandling resident's medications. Staff are utilizing garage as living area. Staff do not meet the physical requirements to care and supervise residents.

On April 18, 2024, Licensing Program Analyst (LPA), Murial Han conducted an unannounced visit to deliver the investigation findings. LPA met with the administrator and explained the purpose of today's visit. Regarding to allegation of facility does not have a substitute administrator, the reporting party stated that the administrator goes on vacation very frequently and there is no one in charge when the administrator is gone. As part of the investigation, LPA interviewed the administrator who denied the allegation and stated that she does not take vacation very frequently and when she does take a vacation, her designated staff would resume the responsibility of the facility and this staff is also a certified administrator. Based on documents provided by the administrator, the LIC 308( Designation Of Facility Responsibility) indicated that the above staff has been designated by the administrator and the administrator provided a copy of the appointed staff's administrator certification. After the investigation, this allegation is deemed to be unfounded. Unfounded Regarding to staff are mishandling resident's medications, there is no additional information forthcoming from the reporting party. However, during the initial reporting, the reporting party stated that the administrator seems to pocket the medication of hospice residents who passed away and they are been diverted to another country/somewhere else. As part of the investigation, LPA interviewed the administrator, reviewed facility's centrally stored medication process and reviewed documents. According to the administrator, when a resident passes away, the administrator is responsible to dispose the remaining medication by completing the Medication Destruction Record and follow the instructions. Once the form is completed and witnessed by a staff member, the administrator will dispose the medication at the local law enforcement department. LPA observed a resident who recently passed away and all of the remaining medication matched the centrally stored medication and destruction record and the administrator would be disposing them at the local law enforcement department. After the investigation, this allegation is deemed to be unfounded. Regarding to allegation of- staff are utilizing garage as living area, the reporting party stated that someone at the facility shared with him/her that the administrator is sleeping in the garage but did not have any additional information. As part of the investigation, LPA interviewed the administrator, staff, and conducted a tour of the facility. The administrator denied the allegation and stated no one lives in the garage as it is being used as a storage room. LPA interviewed staff #1 (S1) who also stated that no ones lives in the garage. LPA toured the garage and observed that it's being used as a storage space. After the investigation, this allegation is deemed to be unfounded. Regarding to allegation of staff do not meet the physical requirements to care and supervise residents, the reporting party stated that staff did not have proper training to care for residents. Based on staff training records provided by the administrator, LPA observed staff training was completed. After the investigation, this allegation is deemed to be unfounded. Based on the above information, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis. Report is reviewed and discussed with administrator, and a copy is provided.the state’s words, verbatim · CDSS document, Apr 18, 2024 · control 14-AS-20240227131710

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 10/7/23 at 5:30PM. LPA met with Luzviminda Tan, Administrator and stated the purpose of the visit. The facility is licensed for a capacity of 6 non-ambulatory residents in rooms 2,3 and 4 of which 3 may receive hospice care services. There are 2 residents receiving hospice services at this time. The Administrator Certificate was observed for Luzviminda Tan which expires 8/26/24. LPA observed residents and conversed with them during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 78.1*F which is within the required range of 68-85*F. The hot water temperature was measured at 105 *F which is within the required range of 105-120*F. Facility has a tankless water heater. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed 1 staff and 2 resident files and conducted interviews during this visit. Upon a file review the following items were discussed to be submitted with any changes annually: Any Addendums to the Infection Control Plan, Plan of Operation, Designation of Facility Responsibility (LIC308), Personnel Report (LIC500) to include the Administrator presence in the facility, Administrator Certificate-Updated, Emergency Disaster Plan (LIC610E), Plan of Operation, Plan for incidental and Medical and Dental Care, Health Screening with TB, Transportation Procedures, and Liability Insurance. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted, a copy of the report was given.the state’s words, verbatim · CDSS document, Oct 7, 2023