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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600536
Report Date: 06/07/2022
Date Signed: 06/07/2022 11:00:44 AM

Document Has Been Signed on 06/07/2022 11:00 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SIERRA GUEST HOMEFACILITY NUMBER:
198600536
ADMINISTRATOR:SHIRAZI, ALI ASGHARFACILITY TYPE:
735
ADDRESS:5039 FIESTA AVENUETELEPHONE:
(626) 309-9266
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY: 6CENSUS: 5DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Marilyn Acabal (Administrator)TIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility LPA met with Marilyn Acabal (Administrator) and explained the purpose of the visit. The facility is approved to serve developmentally disabled adults ages 18 to 59 years old. Four non-ambulatory only.

The facility is located in a residential area. A tour of the single-story facility includes: Living room, dining room, kitchen, 3 bedrooms, 1 staff bedroom, 2 bathrooms, attached garage and a laundry room.

During today’s visit, LPA observed the following: Licensee is not operating beyond the conditions and limitations specified on the license, including the capacity. All clients are protected against hazards. All outdoor and indoor passageways are free of obstruction. There are no pools or large bodies of water on the premises. There are no firearms on the premises and other dangerous weapons such as knives are locked. Disinfectants, cleaning solutions, poisons are inaccessible to clients. A comfortable temperature for clients is maintained. Lamps or lights in all rooms to ensure the comfort and safety were observed. All toilets, hand washing and bathing facilities is safe, sanitary and in operating condition. Hygiene products are readily available. All foods are selected, stored, prepared and served in a safe and healthful manner. Nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days were observed. Freezers and refrigerators are clean, and maintain temperatures. Sufficient staff as necessary to ensure provision of care and supervision to meet client needs were observed. All staff have a criminal record clearance. Staff responsible for direct care and supervision have current first aid. The administrator is on the premises a sufficient number of hours necessary to adequately administer the facility in compliance with applicable law and regulation. All medications are labeled and maintained in compliance with label instructions and State and Federal law. Medications are safe, locked and inaccessible. Hot water temperature measured at 130.7 degree F in the hallway bathroom.

Per Title 22 Regulations, the deficiency observed is documented on LIC809D. Failure to correct the deficiencies may result in civil penalties.

An exit interview was conducted and a copy of this report and appeal rights provided to Marilyn Acabal.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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 06/07/2022 11:00 AM - It Cannot Be Edited


Created By: Kruz Long On 06/07/2022 at 10:18 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SIERRA GUEST HOME
FACILITY NUMBER: 198600536

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)


This requirement is not met as evidenced by: Hot water temperature measured at 130.7 degree F in the hallway bathroom.
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2022
Plan of Correction
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Licensee shall immediately adjust water temperature and maintain a temperature log to ensure that the hot water temperature measures within Title 22 guidelines.

Note: Water temperature was adjusted at time of visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Kruz Long
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022


LIC809 (FAS) - (06/04)
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