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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600536
Report Date: 02/20/2024
Date Signed: 02/20/2024 11:33:45 AM

Document Has Been Signed on 02/20/2024 11:33 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
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: 6DATE:
02/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Marylin Acabal- AdministratorTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of citing deficiencies. LPA Maldonado met with Administrator Marylin Acabal and explained the purpose for the visit.

During a complaint visit conducted at the facility on 2/20/24, LPA met with staff Marites Jacinto and Andres Jacinto. Upon review of staff roster, and Facility Personnel Report, LPA discovered both staff are fingerprint cleared, but are not associated to this facility. Per Administrator, Marylin Acabal, staff have been working here for (2) days.

Per California Code of Regulations, Title 22, deficiencies were observed and will be cited on the LIC809-D.
Immediate Civil Penalties in the amount of $400.00 were issued during today's visit.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2024
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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Document Has Been Signed on 02/20/2024 11:33 AM - It Cannot Be Edited


Created By: Valeria Maldonado On 02/20/2024 at 11:18 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/21/2024
Section Cited
CCR
80019(e)(3)

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80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review...shall prior to working...in a licensed facility: (3) Request a transfer of a criminal record clearance...
This requirement was not met as evidenced by:
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Licensee to associate the (2) staff in question immediately and submit proof of association to LPA via email by POC due date.
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Based on record review, the Licensee failed to associate staff# 1 & 2, prior to them working at the facility, which poses an immediate Health, Safety, or Personal Rights risk to persons 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.
SUPERVISOR'S NAME:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024


LIC809 (FAS) - (06/04)
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