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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600536
Report Date: 04/20/2026
Date Signed: 04/20/2026 03:23:26 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/14/2026 and conducted by Evaluator Mayra Cota
COMPLAINT CONTROL NUMBER: 28-AS-20260414154515
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:
04/20/2026
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Marilyn Acaba, Assistant AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Failure to submit a Special Incident Report (SIR) for client within required
regulatory timelines.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced 10-day complaint visit to investigate the above-mentioned allegation. LPA was greeted by Marites Jacinto, Direct Support Staff. Marilyn Acabal, Assistant Administrator, arrived thereafter and the reason for the visit was explained. Administrator, Ali Asghar Shirazi, was informed about today’s visit via phone call.

The investigation revealed the following:

LPA, toured the facility, conducted interviews with Staff 1 – Staff 2 (S1-S2) and reviewed Special Incident Reports (SIRs) from 4/20/2025 and 11/29/2025.

The investigation revealed the following:
***Continues on LIC 9099-C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20260414154515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SIERRA GUEST HOME
FACILITY NUMBER: 198600536
VISIT DATE: 04/20/2026
NARRATIVE
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The investigation revealed the following:

Regarding: Failure to submit a Special Incident Report (SIR) for client within required

regulatory timelines.



It's alleged that the facility did not provide Special Incident Reports (SIRs) to Community Care Licensing (CCL) in a timely manner.

Record review indicated that the facility sent SIR for incident which occurred on 11/29/2025. LPA confirmed that the department received the SIR on 12/9/2025. However, per interview with S1, the facility did not send the department SIR for C1’s hospitalization which occurred on 4/20/2025. Record review conducted by LPA further indicated that the facility did not send CCL the SIR until 3/20/2026. Interview with S1 further indicated that they did not report C1’s hospitalization because C1 was admitted only for observation and released the next day without needed treatment. Based on record review and interview with S1, the allegation that the facility did not provide SIR to CCL in a timely manner has been corroborated.

Based on interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22), is being cited on the attached LIC 9099 D. An exit interview was conducted with Marilyn Acabal, Administrator, and a copy of this report was provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20260414154515
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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: 04/20/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/04/2026
Section Cited
CCR
80061(b)(1)(E)
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Reporting Requirements: (b) Upon the occurrence, during the operation of the facility, of any of the events specified (1) a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event (1) Events reported shall include the following:
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Licensee will provide proof of training for Reporting Requirements for (2) administrative staff by POC due date. Licensee will also provide LPA with a plan on how to manage reporting to the deparment via SIR by POC due date.
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(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
This requirement is not met as evidenced by:
the facility did not send the department SIR for C1’s hospitalization which occurred on 4/20/2025.
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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.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3