198600536-6-3-2026-28-AS-MCOA-DUNT4X-20260602142439

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600536
Report Date: 06/02/2026
Date Signed: 06/03/2026 09:21:54 AM

Document Has Been Signed on 06/03/2026 09:21 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	SIERRA GUEST HOME		FACILITY NUMBER:	198600536
ADMINISTRATOR/ DIRECTOR:	SHIRAZI, ALI ASGHAR		FACILITY TYPE:	735
ADDRESS:	5039 FIESTA AVENUE		TELEPHONE:	(626) 309-9266
CITY:	TEMPLE CITY	STATE: CA	ZIP CODE:	91780
CAPACITY: 6		CENSUS: 5	DATE:	06/02/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:45 AM
MET WITH:	Marites Jacinto, Direct Support Staff and Mohammed Shirazi, On Call Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:45 PM

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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced Required 1 year visit. LPA was granted entrance and met with Marites Jacinto, Direct Support Personnel, and the purpose of the visit was explained. Marilyn Acabal, Administrator, was informed about today's visit via telephone call. Mohammed Shirazi, On Call Administrator, arrived thereafter and continued to facilitate the visit.

The facility is licensed to serve (6) developmentally disabled adults ages (18) to (59) years of age, which (4) can be non-ambulatory. The facility is operating within the scope of its licence. The facility is in a residential area of Temple City. The single-story home consists of living room, main dining room, kitchen/secondary dining area, laundry room, (3) client bedrooms, (2) full bathrooms, staff lounge, attached garage and front and back yard.

During today's visit, the following was observed:

Facility is clean and walkways, ramps and staircases are free of debris and obstructions. Furniture throughout the facility was observed in good repair. There is sufficient seating. Client bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen. There is a closet in the hallway with extra clean linen and towels for clients.
Kitchen appliances were clean and were operating at the time of visit. Sharps are kept locked in a kitchen cabinet and are inaccessible to clients. Cleaning supplies and toxins are locked in a cabinet under kitchen sink and the garage. Sufficient supply of 2 day perishable and 7 day non-perishable food was observed and additional emergency food supply and water was observed in the garage. Food was inspected and is kept within expiration limits. An over flow refrigerator is kept in the garage and was observed stocked with extra food.

***Continues on LIC 809- C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/02/2026

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Both bathrooms were inspected and were observed clean and sanitary. Showers in both bathroom have grab-bars and anti-slip mats. The water temperature was tested in both bathrooms and measured within the required compliance range of 105 - 120 degrees F. Sufficient personal hygiene supplies for clients are kept in the laundry room. Laundry room appliances observed to be operable and detergents are kept locked in a cabinet.
The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area accessible to clients, located in the backyard. Patio furniture in the back yard was observed clean and in good repair. Garden is maintained and passageways and exits are free of obstruction. Garage was observed free of clutter and is kept locked and inaccessible to clients.
Interconnected smoke detectors were observed throughout the facility and were tested and observed to be working properly. Carbon monoxide detector located in the dining room was also tested and was observed to be working properly. The home is equipped with two fire extinguishers, (1) located by the kitchen and (1) in the laundry room. Both were observed charged and were last inspected on 4/28/2026. Last fire/safety drill was conducted on 5/20/2026. Fireplace in the living room is covered and is inaccessible to clients.
Five (5) client and (5) staff files were reviewed. Client files have Admissions Agreement, Medical Assessment, Consent Forms, Appraisal and Needs and Services plan, I.D and Emergency Information, TB Test, Centrally Stored Medication Record, Personal Rights Form and current Quarterly Behavioral Reports. Staff files have current First Aid/CPR certification, criminal background clearances, health screenings and training documents. Administrator’s certificate for Marilyn Acabal was observed with an expiration date of June 15, 2026.
Medication observed centrally stored, locked and inaccessible to clients. Medication review was also conducted for (5) clients and was observed to be administered and per physician's orders.

Licensee was offered the Technical Support Program (TSP) to assist in maintaining compliance with Title 22 Regulations and the Health & Safety Code. Licensee was informed that participation in the TSP program is voluntarily and free of charge. Licensee indicated that they will discuss the offer with administrator and will later confirm with LPA

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies noted and no citations issued during today's visit. Exit interview was held with Mohammed Shirazi, and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

LIC809 (FAS) - (06/04)

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