198600536-6-10-2026-28-AS-MCOA-DUWPKX-20260610112353

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600536
Report Date: 06/10/2026
Date Signed: 06/10/2026 11:25:30 AM

Document Has Been Signed on 06/10/2026 11:25 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:	06/10/2026
TYPE OF VISIT:	Office	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Ali Shirazi, Licensee and Marilyn Acabal, Administrator		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	An informal meeting was held today at the Monterey Park Adult and Senior Care Licensing office. Adeline Ho, Licensing Program Manager (LPM) and, Mayra Cota, Licensing Program Analyst (LPA), met with Ali Shirazi, Licensee and Marilyn Acaba, Administrator. The reason for the meeting was explained to the participants. During the office meeting the following was discussed: Reviewed facility’s compliance for past substantiated complaints. · Complaint visit conducted on 4/2/2026. Citation issued for Section 80065(a) Personnel Requirements: Staff competency. · Complaint visit conducted on 4/20/2026. Citation issued for Section 80061(b)(1)(E) Reporting Requirements: SIR not sent to the department. Discussed care and supervision concerns. · It was observed that a child (unauthorized person) was on the premises, co-mingling with clients in care during a visit. · Per interview, Administrator permitted the presence of a child in the home which posed a safety risk for child and clients in care. Staff responsiveness to communication from the department. · Administrator has been non-responsive to LPA’s communication. · LPA sent out several emails in attempts to get statuses on POCs which were not cleared by due date. *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: 06/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2026

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: 06/10/2026

NARRATIVE

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·LPA attempted to obtain documentation for exceptions requests; however, administrator did not follow through.
· Per record review and information obtained from the administrator, the facility did not inform the department via Special Incident Reports (SIR) regarding client hospitalization.
Duties and responsibilities of the administrative staff.
· Provide care and supervision to clients in care.
· Ability to communicate with staff, clients and agencies.
· Support staff in any capacity.
· Monitor and maintain records.
· Comply with applicable law and regulation.
· Administrator’s certificate expires on 6/15/26.

Client and Personnel Records.

· LPA observations made by LPA during visits to the facility.
· Client files were incomplete. Quarterly Behavioral reports were missing.
· Staff files were also incomplete. Files were missing copies of current First Aid/CPR certification. Also observed, expired certification who have direct contact with clients.

Licensee was offered the Technical Support Program (TSP) to assist with the licensee 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 and Administrator agreed to be referred to TSP. Facility’s annual fees are current.

Facility’s participation in the Technical Support Program (TSP) and areas of focus.

· Administrator – Qualifications and duties.
· Maintaining client and staff files.
· Reporting requirements.
***Continues on LIC 809-C page 2***

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2026

LIC809 (FAS) - (06/04)

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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: 06/10/2026

NARRATIVE

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During today's meeting, the following Title 22 Regulation Sections were discussed and materials below were provided during the meeting:

80044 Inspection Authority of the Licensing Agency
80053 Follow-up Visits to Determine Compliance
80064 Administrator - Qualifications and Duties
85064 Administrator Qualifications and Duties
80065 Personnel Requirements
85065 Personnel Requirements
80061 Reporting Requirements
85061 Reporting Requirements
80070 Client Records
85070 Client Records
80066 Personnel Records
85066 Personnel Records
LIC 311C Records to be maintained at the facility
Technical Support Program (TSP) brochure

Licensee will submit the following items listed below to LPA by 6/29/26.
· Proof of staff training: review policy regarding unauthorized persons at the facility and staff duties to ensure care and supervision of clients in care.
· Proof of training: Licensee will provide proof of training for Reporting Requirements for (2) administrative staff.
· Care Plan and support letter from Regional Center regarding the use of a helmet for Client 1.
· LIC 308 for designation of facility responsibility.
· Submit the Change of Administrator request with required documentation.

Licensee agrees to do the following to maintain compliance with Title 22 regulations.
· Administrator will improve communication with the Department
· Administrator will consistently monitor the day-to-day facility operations.
· Administrator will submit POCs in a timely manner.
***Continues on LIC 809-C page 3***

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2026

LIC809 (FAS) - (06/04)

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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: 06/10/2026

NARRATIVE

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LPA Adeline Ho provided the following advises:

· Further lack of communication and non-compliance with regulations will lead to a non-compliance conference with the Regional Manager and may warrant additional visits.
· Failure to correct and submit Plan of Corrections by due date will lead to civil penalties and may warrant administrative actions.
· Administrator will submit incident reports (SIRs) in a timely manner.

An exit interview was held. A copy of this report was provided to Licensee and Administrator

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2026

LIC809 (FAS) - (06/04)

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