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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600536
Report Date: 04/26/2024
Date Signed: 04/27/2024 11:54:55 AM

Document Has Been Signed on 04/27/2024 11:54 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SIERRA GUEST HOMEFACILITY NUMBER:
198600536
ADMINISTRATOR/
DIRECTOR:		SHIRAZI, ALI ASGHARFACILITY TYPE:
735
ADDRESS:5039 FIESTA AVENUETELEPHONE:
(626) 309-9266
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY: 6CENSUS: 5DATE:
04/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:44 PM
MET WITH:Administrator Marilyn AcabalTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 04/26/2024 at 12:44 pm. LPA was met by caregiver Marites Jacinto and explained the purpose of the visit. Administrator Marilyn Acabal arrived shortly after and assisted in tour of facility. Facility is licensed to serve clients 18 to 59 years old. The facility has a fire clearance approved for four (4) non-ambulatory. There are four (4) level 4C developmentally disabled clients residing at this facility. Clients at this facility are receiving services from East Los Angeles Regional Center. LPA requested and obtained a copy of Personnel Report, and Resident Roster.

LPA OBSERVATIONS: Tour began at 12:55 pm. The facility is a single-story building located in a residential area with three (3) client bedrooms, one (1) staff office, two (2) bathrooms, kitchen, dining room, front yard, backyard, and detached garage.

· Front Yard: Was clean and well maintained. No hazards were observed.

· Kitchen: LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7-day supply on non-perishables. At 1:00pm, LPA observed knives and sharps located in nearby cabinet to be inaccessible to 5 out of 5 clients in care. LPA observed several bottles of cleaning solutions and disinfectants under kitchen sink cabinet to be inaccessible to 5 out of 5 clients in care.

· Dining Room/Living room: Dining room was observed to be clean and contained one table and chairs. Living room was observed to contain 2 sofas, 1 recliner and contained plenty of lighting. LPA observed nearby thermostat located on living room wall to read 74 degrees F.

· Linen Closet: Contained plenty linens, towels, and hygiene products.

· Client Rooms 1 - 3: All contained the required furnishings, linens and were observed to be clean with plenty of closet space. All client bedrooms are shared.

SEE 809-C for continuation...

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 198600536
VISIT DATE: 04/26/2024
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· Bathrooms: Shared client bathroom# 1 was observed to be clean and contained soap and paper towels. Signs promoting hand washing were observed. Water temperature in this bathroom was within the required 105 – 120 degrees F. Bathroom #2 located in client bedroom #3, was observed to be clean and water temperature was within the required 105 -120 degrees F.

· Centrally Stored Medications: LPA observed cabinet located in kitchen to be locked and inaccessible to residents. LPA reviewed 5 client medications and Medication Administration Record (MAR).

· Backyard: Clean and free from hazards. LPA observed plenty of seating and shade. No large bodies of water were observed.

Personnel Records: Personnel records are maintained at the facility. LPA Ramirez reviewed three (3) personnel records. First Aid Certificate, Fingerprint Clearance/ Exemptions, Personnel Record/Job Application, Health Screening, Employee Rights, TB Test, and Initial/Annual Training Verification. Administrator’s certificate for Marilyn Acabal was observed with an expiration date of 11/18/2024.

Client Records: Client files are maintained at the facility. LPA Ramirez reviewed five (5) client records. No deficiency was observed. Admissions Agreement, Medical Assessment, Consent Forms, Appraisal and Needs and Services plan, I.D and Emergency Information, TB Test, Centrally Stored Medication Record, and Personal Rights Form.

Infection Control Plan: Facility maintains approved infection control plan.

No deficiencies are being cited during visit. Exit interview was conducted with Administrator Acabal and a copy of this report, and appeals rights was provided via email due to printer problems.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024
LIC809 (FAS) - (06/04)
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