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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600536
Report Date: 11/14/2024
Date Signed: 11/15/2024 02:46:21 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
02/16/2024 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240216132226
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:
11/14/2024
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Marites Jacinto, DSPTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff threw water on a resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint investigation for the allegation listed above. LPA met with Staff, Marites Jacinto, and explained the reason for the visit.

The investigation consisted of the following:
On 2/20/24 and 5/7/24, LPA Valeria Maldonado visited the facility to tour the physical plant, collect documents, and interview Staff #1 - #3.
On 11/14/24, LPA Chan interviewed additional Staff and Clients. Client #1 is no longer residing at the facility and was not interviewed.

The investigation revealed the following:
Allegation – Staff threw water on a resident. It is alleged Staff #1 (S1) dumped a bucket of water on Client #2.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
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 5
Control Number 28-AS-20240216132226
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/14/2024
NARRATIVE
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According to LPA Maldonado’s interviews with staff, they did not witness Staff #1 (S1) dumping a bucket of water or wetting Client #2 with a water hose. However, the Eastern Los Angeles Regional Center Quality Assurance Specialist conducted their investigation and interviewed staff. It was determined that one of the staff witnessed the event of S1 trying to shower the client in the backyard and heard C2 screaming no. The staff questioned S1’s actions and immediately informed the administrator following the incident. The staff is no longer working at the facility and LPA could not reach S1.

Based on records gathered, 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 1), are being cited on the attached LIC 9099D.



An exit interview was conducted. The Plan of Correction was reviewed and developed with the administrator via telephone. A copy of this report and appeal rights were provided to the staff.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20240216132226
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2024
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights...(1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement is not met as evidenced by:
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The licensee shall conduct an in-service training to staff on personal rights. The licensee shall ensure all staff receive personal rights training annually.

**The staff is no longer working at the facility. This POC has been cleared. ***
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Based on interviews, S1 wetted the client with the water hose which posed a potential health, safety, and personal rights risk to clients in care.
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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.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
02/16/2024 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240216132226

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:
11/14/2024
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Marites Jacinto, DSPTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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1. Resident sustained unexplained bruising while in care.
2. Staff do not meet resident's dietary needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint investigation for the allegations listed above. LPA met with Staff, Marites Jacinto, and explained the reason for the visit.

The investigation consisted of the following:
On 2/20/24 and 5/7/24, LPA Valeria Maldonado visited the facility to tour the physical plant, collect documents, and interview Staff #1 - #3.
On 11/14/24, LPA Chan interviewed additional Staff and Clients. Client #1 is no longer residing at the facility and was not interviewed.

The investigation revealed the following:
Allegation – Resident sustained unexplained bruising while in care. It is alleged Client #1 (C1) sustained bruises while living at the facility. LPA reviewed Client #1’s file and Regional Center reports.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20240216132226
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/14/2024
NARRATIVE
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C1 moved in on 1/9/24 and observed several body check forms which staff documented areas of marks/bruises noticed on client. It was also documented that police officers conducted body check on C1 on two visits and no bruises or injuries were found. Regional Center had also investigated on this suspicion of physical abuse. Based on their interviews, there was no sufficient evidence to show that the bruises were caused by staff member(s). It was shared that the bruises could have been from sleeping with toys, getting up from the table hastily, walking into the walls, or from another client who would sometimes grab C1. LPA attempted to contact 2 staff who were working during the time C1 was residing at the facility but was not successful. The staff are no longer working at the facility.
LPA interviewed 3 out of the 5 clients residing at the home and all 3 stated they like living here. They said that staff are nice and have never been hurt by any staff. There is no sufficient evidence to prove this allegation.

Allegation – Staff do not meet resident’s dietary needs. It is alleged that Client #1 (C1) lost 5 lbs since moving in 4 weeks ago and scarfs down food. The administrator stated that C1 was picky with food but was given options to get proper food intake. Staff interviewed stated C1 did not have any diet restrictions and ensured clients ate their meals. They also stated that C1’s family member(s) often came and brought food. LPA interviewed the 3 clients today and all stated they are well fed. They recalled C1 eating together at the dining table during meal time. LPA observed the refrigerator to be filled with variety of meats, fruits, and vegetables.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.



An exit interview was conducted with Staff M. Jacinto. A copy of this report along with the appeal rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5