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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601051
Report Date: 05/22/2023
Date Signed: 05/22/2023 01:45:51 PM

Document Has Been Signed on 05/22/2023 01:45 PM - 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:KEY WEST GUEST HOME, INC.FACILITY NUMBER:
198601051
ADMINISTRATOR:SHIRAZI, ALI ASGHARFACILITY TYPE:
735
ADDRESS:10336 KEY WEST STREETTELEPHONE:
(626) 444-0850
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY: 6CENSUS: 6DATE:
05/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Concepcion Pacania - Lead StaffTIME COMPLETED:
01:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Concepcion Pacania (Lead Staff) and explained the reason for the visit. The facility is licensed to serve Six Developmentally Disabled (DD) Adults and Room #4 is approved for 2 Non-Ambulatory.

The facility is a single-story home located in a residential area consisting of: three (3) client bedrooms, (2) Staff Bedrooms, 2 bathrooms, kitchen area, dining area, living room, covered patio area, and a detached garage.



LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan.
Physical Plant & Environment Safety: There are 3 client bedrooms, 2 staff bedrooms, 2 client bathrooms, living room, kitchen, dining area. Clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The outdoor and passageways are free of obstruction. There are no security bars or weapons on the premises. Hygiene products are readily available and stored in hallway closet. The hot water temperature was tested in both client bathrooms. The water temperature measured between 113.5-114.6 degrees F, these are within the required range of 105-120 degrees. Both front and back yard are free of debris/hazards. All storage areas for cleaning solutions, and toxins are stored in a locked cabinet under the kitchen sink. The knives and sharp items are securely stored in a locked drawer in the kitchen.
(Continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2023
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 5
Document Has Been Signed on 05/22/2023 01:45 PM - It Cannot Be Edited


Created By: Tena Herrera On 05/22/2023 at 12:15 PM
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: KEY WEST GUEST HOME, INC.
FACILITY NUMBER: 198601051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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During review of medication LPA observed medication of Resident #1 (Levetiracetam 1,00 MG Tablet #124 [for seizures]) was not administered during morning medication distribution. Staff confirmed that this was an error which poses an immediate health, safety and/or personal rights risk to the clients in care.
POC Due Date: 05/23/2023
Plan of Correction
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Administrator/Licensee will provide inservice training to staff over the weekend (5/27/23-5/28/23). Administrator/Licensee will provide material on what will be coverd during training to LPA via email by end of business day on 5/23/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/22/2023 01:45 PM - It Cannot Be Edited


Created By: Tena Herrera On 05/22/2023 at 12:15 PM
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: KEY WEST GUEST HOME, INC.
FACILITY NUMBER: 198601051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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During review of facility files, LPA observed last documented fire drill took place in Dec. 2022. This poses a potential health, safety and/or personal rights risk to the clients in care.
POC Due Date: 05/23/2023
Plan of Correction
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Amdninistrator/Licensee will conduct a fire/emergency drill later this evening once all clients are back from day program and email LPA with the updated log by end of business day 5/23/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023


LIC809 (FAS) - (06/04)
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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: KEY WEST GUEST HOME, INC.
FACILITY NUMBER: 198601051
VISIT DATE: 05/22/2023
NARRATIVE
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The last Fire/Emergency Drill was conducted in December 2022 with no record of ongoing fire drills for 2023. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed in the dining area and kitchen, both are fully charged.
Operational Requirements: There are currently 6 non-ambulatory clients residing at the facility. There is an outdoor activity area that is shaded and furnished for outdoor use.
Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Marilyn A. Acabal certificate expires on 11/18/2024.
Personnel Records-Training: Staff has criminal record clearance. Staff has current first aid and CPR. Staff files are maintained at the facility located in a locked cabinet in the living room. Staff have current CPR/first aid training and sufficient on-going training.
Resident Rights-Information: Clients personal rights poster is posted in the dining area. The facility provides internet and telephone access for the clients in care.
Resident Records-Incident Reports: Client files are kept in a locked closet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication has the proper annual training on file. Medication is centrally stored in a locked cabinet in kitchen and are in their original containers. During the visit today, LPA reviewed all 6 clients' medication with Resident #1(R1) missing a dosage as the medication was still in the bubble packaging. There was a staff initial that medication was administered in the morning, however, medication was still in packaging.
Incidental Medical & Dental: All medications for clients are kept locked in a kitchen cabinet and inaccessible to other clients.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Emergency Intervention: Residents at this facility do not have restraints nor do they require the use de-escalation techniques.

(Continued on 809-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: KEY WEST GUEST HOME, INC.
FACILITY NUMBER: 198601051
VISIT DATE: 05/22/2023
NARRATIVE
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LPA conducted 2 staff interviews during todays visit. No client interviews were done as they were away at day program

California Code of Regulations, Title 22, Division (6) and Chapter (1) is being cited along with on the attached LIC 809D's.

Exit interview held and a copy of the report and appeal rights were provided to the Lead Staff Concepcion Pacania.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5