<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600536
Report Date: 07/20/2023
Date Signed: 07/20/2023 03:26:32 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/14/2023 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230714142209
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:
07/20/2023
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Marilyn AcabalTIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to designate a backup administrator
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Angelica Rea conducted an initial complaint visit in response to the allegation listed above. LPA met with Staff, Angelica Mendoza who allowed entry into the facility. Administrator, Marilyn Acabal was not at the facility at the time of the visit. Ms. Mendoza called Administrator via telephone to notify her of the visit. Ms. Acabal arrived at the facility a short time later.

Regarding the allegation that : Facility failed to designate a backup administrator. The investigation consisted of review of Corrective Action Report (CAP) issued by the Eastern Los Angeles Regional Center (ELARC) dated 7/14/23, interview with ELARC QA and Compliance Specialist, and interview with Administrator. Per CAP report, Administrator failed to designate a backup administrator during the month of June 2023. Administrator stated that she had a family emergency and had to leave the country during the period of 5/26/23-6/4/23. She stated that she is the administrator of the facility and she designated Mr. Mohammed Shirazi as the authorized representative in her absence. Ms. Acabal stated that she did not submit the Designation of Facility Responsibility to Community Care Licensing as required.



Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
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-20230714142209
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SIERRA GUEST HOME
FACILITY NUMBER: 198600536
VISIT DATE: 07/20/2023
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
26
27
28
29
30
31
32
 Based on LPA's observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 6 are being cited on the attached LIC 9099D.

Copy of report, and appeal rights provided to Administrator, Ms. Acabal.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20230714142209
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 07/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2023
Section Cited
CCR
85064(f)
1
2
3
4
5
6
7
When the administrator is absent from the facility there shall be coverage by a designated substitute, who meets the qualifications of Section 80065, who shall be capable of, and responsible and accountable for, management and administration of the facility in compliance with applicable law and regulation.
1
2
3
4
5
6
7
Administrator stated that she will provide documentation, appointing her as administrator. Administrator will also provide an LIC 308 to CCL as required. Administrator will provide the above documentation by POC due date.
8
9
10
11
12
13
14
This requirement is not being met as evidenced by: Administrator admitted to leaving the country on 5/26/23 - 6/4/23, and not submitting a Designation of facility responsibility as required.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3