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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601051
Report Date: 06/12/2024
Date Signed: 06/12/2024 12:35:29 PM

Document Has Been Signed on 06/12/2024 12:35 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:KEY WEST GUEST HOME, INC.FACILITY NUMBER:
198601051
ADMINISTRATOR/
DIRECTOR:		SHIRAZI, ALI ASGHARFACILITY TYPE:
735
ADDRESS:10336 KEY WEST STREETTELEPHONE:
(626) 444-0850
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY: 6CENSUS: 5DATE:
06/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:31 AM
MET WITH:Concepcion Pacania, DPSTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Sanjay Vaid initiated a case management visit to follow-up on the death of Client #1(C1). At 1125AM Concepcion Pacania was present at the facility, contracted administrator via phone. Administrator Marilyn Acabal had previous appointment and could not conduct case management visit. Concepcion Pacania will sign on Administrator Acabal’s behalf.

Facility completed death report for C1 dated 05/30/2024. C1 passed away at Arcadia Methodist Hospital on 05/30/2024. According to the report, on 05/15/24 the client’s physician prescribed medication to be taken daily every 8 hours for 5 days as needed for phlegm and intermittent cough. On 05/22/24 staff informed the physician that the client had continuous and productive cough and phlegm. On 05/26/24 at 5:40 pm C1 was not able to spit out the phlegm accumulated in C1’s throat and was observed by staff having a hard time clearing the phlegm in the throat and chest. Staff called paramedics and transported C1 to San Gabriel Valley Medical Center, physician on duty ordered chest Xray, urine and blood work for influenza A and B and Covid antigen tests. On 05/28/24 C1 was seen by a personal physician who ordered Nebulizer, Albuterol to be administered by Home Health. At 6:40 pm after C1 returned to the facility, the Administrator observed C1 congestion not improving with abnormal breathing patterns, staff call 911 and was taken to Arcadia Methodist Hospital and admitted for further treatment. C1 was intubated on the night of 05/28/24, on 05/29/24 C1’s mother and sister signed an advanced directive and intubation was removed. On 05/30/24 at 1am C1 passed away according to family members. The official cause to death is Respiratory Failure, Pneumonia.

LPA reviewed the facility file for client #1 were received and reviewed on 06/11/2024; Needs & Service Plan, physicians report and IPP. LPA requested copies of the following documents be mailed to licensing: Death Certificate. Administrator is working with C1's family to obtain the Death Certificate.

Continued on 809C...
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: KEY WEST GUEST HOME, INC.
FACILITY NUMBER: 198601051
VISIT DATE: 06/12/2024
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LPA reviewed the facility file for client #1 were received and reviewed on 06/11/2024; Needs & Service Plan, Physicians Report and IPP. LPA requested copies of the following documents be mailed to licensing: Death Certificate. Administrator is working with C1's family to obtain the Death Certificate.

LPA conducted a tour of the facility with DSP Concepcion Pacania. The tour included 3 client's bedrooms, two clients share room, 2 bathrooms, kitchen, dining room, living room, and common areas. LPA observed sharps, toxins, and medications under lock and inaccessible to clients. There were no health and safety concerns at the time of the visit.

Exit interview was held and a copy of the report was provided to the facility.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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