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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601051
Report Date: 02/22/2024
Date Signed: 02/22/2024 12:27:18 PM

Document Has Been Signed on 02/22/2024 12:27 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:
02/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Concepcion Pacania - Staff TIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Concepcion Pacania and explained the reason for the visit.

The facility is licensed to serve 6 development disabled adults between the ages of 18-59 years old of which two may be non-ambulatory in room #4. 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 Flores conducted a tour of the facility with Concepcion Pacania and observed the following:
Kitchen area was observed clean and in good repair. Sufficient food supplies were observed for at least 2 days on perishables and 7 days of non-perishables. Medication, cleaning supplies, and sharps were observed locked. Dining room and living room were observed clean, in good repair, and furnished. Client rooms (4) were observed with the required furniture, sufficient lighting, and bedding supplies. Room #5 was observed with a hole in the entry wall by light switch with a hole of about 12inx3in. Bathrooms (2) were observed clean, in working condition, with grab bars and skid mats. Water temperature was tested in the bathrooms and tested as follow: bathroom #1(B1) 121.6 degrees F., and bathroom #2 tested at 118.2 degrees F., which is not within the required 105-120 degrees F. Smoke/Carbon Monoxide detectors were tested and in working condition. Backyard has a covered patio and sitting furniture was observed. Passageways are cleared of debris, and obstructions. Fire extinguisher was observed and last checked on 4/26/23.
LPA reviewed 5 clients' medication, files, and P&I money. (3) staff files were available for review, Staff #2 and #5 files were not available at the facility for review. Administrator certificate was observed #6017661735 exp.date: 6/15/24. Last HIV/TB training taken by administrator was on 4/19/20. Infection control plan was reviewed. Emergency disaster plan (version 10/03) was reviewed.
Deficiencies were noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Marilyn Acabal and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024
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 02/22/2024 12:27 PM - It Cannot Be Edited


Created By: Mary G Flores On 02/22/2024 at 12:01 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: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in water temperature tested in bathroom #1(B1) tested at 121.6 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Administrator will adjust water heater and will submit in writting of adjustment and certifying that will ensure water temperature is maintain within the required 105-120 degrees F., by POC due date 2/23/24. Administrator will maintain a temperature log of water tested in each bathroom daily for 7 days and will submit the log by 2/29/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/22/2024 12:27 PM - It Cannot Be Edited


Created By: Mary G Flores On 02/22/2024 at 12:01 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: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in a hole of about 12inx3in was observed in room #5 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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Administrator will have the hole cover/fix and will submit a picture of correction to the department by POC due date 2/29/24.
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in administrator did not have a TB/HIV training within the last 2 years as last TB/HIV was taken on 4/19/20 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2024
Plan of Correction
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Administrator will take and submit a copy of TB/HIV training by POC due date 3/7/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/22/2024 12:27 PM - It Cannot Be Edited


Created By: Mary G Flores On 02/22/2024 at 12:11 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: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
80066 Personnel Records:
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in staff #2 and #5 files were not available for review at the facillity which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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Administrator will submit copies of health screening, TB test clearance, personnel record, staff training, first aid, and clearance letter for staff #2 and #5 to the department by POC due date 2/29/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024


LIC809 (FAS) - (06/04)
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