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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600536
Report Date: 06/12/2023
Date Signed: 06/12/2023 06:47:31 PM

Document Has Been Signed on 06/12/2023 06:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 4DATE:
06/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Marilyn AcabalTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management- Incident visit to follow up on Death Report (LIC 624A) submitted to this licensing agency on 06-09-2023. Client #1 (C1) was discovered in their bed having labored breathing and not responding to staff on 06-08-23 around 9am. Immediate cause of death is unknown at this time pending coroner investigation. Between 8:45 am and 9am Staff #1 (S1) entered C1’s room and found C1 to have labored breathing and unresponsive. Staff called 911 and performed CPR until paramedics arrived. C1 was pronounced deceased by first responders upon arrival.

During today’s visit, LPA requested and obtained a copy of C1’s file including current medical assessment (annual and monthly report), C1’s most current IPP, most recent physician’s orders, most recent Functional Capability Assessment, Admissions Agreement, Medications List, and most recent physician’s report. LPA conducted two staff interviews. LPA requested and obtained a copy of Staff #1 (S1) file and contact information. LPA requested facility obtain a copy of the death certificate and forward the certificate to this licensing agency.

At this time there are no deficiencies to cite. LPA will continue to gather additional information from staff and other agencies. LPA will return once additional information is gathered. A copy of this report was emailed due to printer problems.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2023
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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