198600536-12-9-2025-28-AS-WSHO-DQLM7K-20260123082140

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600536
Report Date: 12/09/2025
Date Signed: 12/09/2025 12:55:19 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
12/01/2025 and conducted by Evaluator Blanca Gonzalez

COMPLAINT CONTROL NUMBER: 28-AS-20251201112715

FACILITY NAME:	SIERRA GUEST HOME		FACILITY NUMBER:	198600536
ADMINISTRATOR:	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:	12/09/2025
		UNANNOUNCED	TIME BEGAN:	08:54 AM
MET WITH:	Marilyn Acabal,		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Due to lack of supervision, resident eloped

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced initial complaint investigation visit on 12/09/2025 regarding the above allegations. During today’s visit, LPA Gonzalez was greeted by staff and the purpose of the visit was explained. Administrator Marilyn Acabal arrived shortly after to assist.

The investigation consisted of the following: LPA Gonzalez requested and obtained copies of staff schedule, Client Roster, interviewed staff #1-2 (S1- S2) and reviewed facility files for client 1 (C1) consisting of face sheet/ID page, admission agreement, physician’s report, IPP, functional assessment, and any documents regarding the incident.

continued on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Blanca Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20251201112715

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/09/2025

NARRATIVE

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continued from LIC 9099

The investigation revealed the following: regarding the allegation “Due to lack of supervision, resident eloped” it is alleged that C1 was taken to USC Arcadia Hospital under a 5150 hold for being gravely disabled due to a sheriff’s department call about someone found wandering in the middle of the street. It was reported that C1 is non-verbal, developmentally delayed, and has the mental capacity of a child. No identifying information such as name, date of birth, or address was obtained, therefore C1 was brought to the Emergency Room as a John Doe. Interviews with staff revealed staff was aware of C1 walking away from the facility. Per facility protocol, staff followed C1 at a safe distance asking C1 to wait. C1 continued walking away. Staff kept their distance to avoid triggering C1’s elopement. Staff lost sight of C1 in a shopping center familiar to clients and staff, as they walk to the shopping center 2-3 times a week. After a few hours of searching for C1 at the shopping center and other familiar stops along their usual walk route, S1 returned to the facility and called law enforcement. With the assistance of the Sheriff’s department, S1 located C1 at a local hospital. S1 was able to retrieve C1 from the hospital with proper identification. A review of C1’s physician’s report signed 07/17/2025, revealed C1 is able to leave the facility unassisted.

Based on interviews and record review, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Marites Jacinto , DSP.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Blanca Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025

LIC9099 (FAS) - (06/04)

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