Acorn Oaks Manor IV

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee/Administrator Maria Williams. According to the facility’s license, the facility has a maximum capacity for six (6) residents, of whom all may be ambulatory or non-ambulatory, and one (1) may be bedridden. Per LPA observation, LIC602 Physician’s Reports, and staff interviews: During today’s inspection, there were a total of three (3) residents, of whom three (3) were non-ambulatory. LPA interviewed multiple staff and multiple clients. LPA also reviewed the care records for all clients, and the personnel files for multiple active staff. LPA also toured the interior and exterior of the facility and inspected all common areas and bedrooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and shower were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was complaint at 73 F. Where tested, hot water temperature at taps accessible to clients were compliant in temperature: Bathroom #1 Sink was 109.2 F and Bathroom #2 Sink was 109.4 F. Appliances to preserve perishable food were also compliant in temperature. Cooking/dining equipment and utensils were present and in good condition. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] There was no fireplace or swimming pool (or similar bodies of water) on the premises. There were no sharp/hazardous objects, toxic chemicals/poisons, or open-faced heaters accessible to residents. Centrally stored medications and confidential records were kept in locked areas. Per the Licensee, no firearms or ammunition are kept at the facility. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present. Carbon monoxide detectors, smoke alarms, night lights, and emergency lighting were working. The facility’s fire extinguisher was serviced within the last twelve (12) months. A complete First Aid kit was present. Required licensing postings were observed in visible areas of the facility. There were reserve supplies of Personal Protective Equipment (PPE). During review of resident records, LPA observed, and manager interview confirmed: For 3 of 3 residents Licensee did provide a care conference meeting with in the past twelve months within the last twelve (12) months arrange a care conference meeting, to include the resident, their responsible person, their home health or hospice agency personnel (where applicable), and facility staff, as required. During review of training records, LPA observed all needed forms were signed and/or initialed . No deficiencies were cited per California Code of Regulations, Title 22, and no deficiencies were cited per California Health and Safety Code. An exit interview was conducted with Licensee/Administrator Maria Williams, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TV page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today's visit.the state’s words, verbatim · CDSS document, Aug 20, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Supervisor Jamily “Jamila” Hallak. LPA then met with Licensee/Administrator Maria Williams, who arrived shortly after. According to the facility’s license, the facility has a maximum capacity for six (6) residents, of whom all may be ambulatory or non-ambulatory, and one (1) may be bedridden. Per LPA observation, LIC602 Physician’s Reports, and staff interviews: During today’s inspection, there were a total of five (5) residents, of whom four (4) were non-ambulatory and one (1) was bedridden. LPA interviewed multiple staff and multiple clients. LPA also reviewed the care records for all clients, and the personnel files for multiple active staff. LPA also toured the interior and exterior of the facility and inspected all common areas and bedrooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and shower were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was complaint at 73 F. Where tested, hot water temperature at taps accessible to clients were compliant in temperature: Bathroom #1 Sink was 109.2 F and Bathroom #2 Sink was 109.4 F. Appliances to preserve perishable food were also compliant in temperature. Cooking/dining equipment and utensils were present and in good condition. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] There was no fireplace or swimming pool (or similar bodies of water) on the premises. There were no sharp/hazardous objects, toxic chemicals/poisons, or open-faced heaters accessible to residents. Centrally stored medications and confidential records were kept in locked areas. Per the Licensee, no firearms or ammunition are kept at the facility. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present. Carbon monoxide detectors, smoke alarms, night lights, and emergency lighting were working. The facility’s fire extinguisher was serviced within the last twelve (12) months. A complete First Aid kit was present. Required licensing postings were observed in visible areas of the facility. There were reserve supplies of Personal Protective Equipment (PPE). Licensee presented proof of current business liability insurance. During review of resident records, LPA observed, and manager interview confirmed: For 4 of 5 residents [Resident #1 (R1) through Resident #4 (R4)], Licensee did not within the last twelve (12) months arrange a care conference meeting, to include the resident, their responsible person, their home health or hospice agency personnel (where applicable), and facility staff, as required. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] During review of training records, LPA observed, and manager interview confirmed: Licensee did not ensure that 16 of 16 staff [Staff #1 (S1) through Staff #16 (S16)] were trained on Personal Protective Equipment (PPE) within the last year, as required. Licensee did not ensure that 16 of 16 staff (S1 through S16) were trained on the facility’s written Emergency and Disaster Plan within the last year, as required. While Licensee did perform two (2) fire drills within the last calendar year, these fell short of the emergency/disaster drill frequency and variety required by regulation. Two (2) deficiencies were cited per California Code of Regulations, Title 22, and two (2) deficiencies were cited per California Health and Safety Code (refer to the LIC809-D pages). Plans of Correction were jointly developed with the Licensee. LPA issued one (1) Technical Violation (TV) regarding tracking of residents’ body weights (refer to the LIC9102-TV page). An exit interview was conducted with Licensee/Administrator Maria Williams, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TV page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today's visit.the state’s words, verbatim · CDSS document, Aug 14, 2025

Type of visit: Post Licensing

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] [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.the state’s words, verbatim · CDSS document, Nov 22, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Debbie Correia conducted an announced Pre-Licensing visit. LPA identified herself to Applicant Maria Williams and was granted entry into the facility. The purpose of today's visit was to inspect the facility to ensure compliance with California Code of Regulations, Title 22, Division 6. The fire inspection was completed on 11/30/23 and the facility is approved for 6 non-ambulatory residents, 1 of which may be bedridden in room 4. The facility has an approved Hospice waiver for 2 residents. During today's visit, LPA toured the facility and inspected all common areas, outside spaces, and resident rooms across the facility. The facility was found to be clean, safe, and in good repair with no pathway obstructions. Private and common resident bathrooms were observed to be clean and the toilets and showers were observed to be in working order, with grab bars and a non-skid shower floor mat. The facility's water temperature of resident bathrooms measured at 109.3 degrees Fahrenheit. LPA observed locked storage areas where all hazardous and/or toxic chemicals were stored and secured. LPA also observed locked storage for resident medications and files. Fire extinguisher was observed and found to be in compliance. Functioning carbon monoxide detector and smoke detectors were observed in the facility. Facility is equipped with a first aid kit and manual and PPE supplies. No bodies of water were observed near or on the premises. Per Applicant Williams there will be no firearms kept on the premises. Required postings were observed in a common area of the facility. LPA reviewed the applicant's Infection Control Plan and Emergency Disaster Plan. LPA conducted Component III with the applicant. The topics discussed were continuing operation requirements, record keeping/reporting, and physical plant compliance. Pre-licensing is complete, and this facility has no deficiencies. It is recommended that this facility be licensed pending final review and approval. An exit interview was conducted with the Applicant Maria Williams, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights.the state’s words, verbatim · CDSS document, Aug 6, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 COMP II Participant: Maria Williams, Managing Member/Administrator Interview Method: Telephone interview On 7/19/24, 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, Jul 19, 2024