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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601051
Report Date: 01/21/2025
Date Signed: 01/21/2025 11:43:46 AM

Document Has Been Signed on 01/21/2025 11:43 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
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:
01/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:33 AM
MET WITH:Laed Direct Staff Person, Concepcion PacaniaTIME VISIT/
INSPECTION COMPLETED:
11:13 AM
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Licensing Program Analyst (LPA) Vaid 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. Currently the five clients are 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 attached garage.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
1.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. Staff is following COVID 19 precautions, temperature readings, masks and gloves are utilized.
2.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 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. The Fire/Emergency Drill was conducted on 12/26/24. Fire and smoke alarms were tested on 12/20/24.
CONTINUED ON 809C.........
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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: 01/21/2025
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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, last serviced on 04/28/2024.
3.Operational Requirements: There are currently 5 non-ambulatory clients residing at the facility. There is an outdoor activity area that is shaded and furnished for outdoor use. Staff participating in activities with clients was observed. Activities calendar is posted in dining room.
4.Staffing: There appears to be always sufficient staffing in the facility. Administrator Marilyn A. Acabal and staff certificates are up-to date.
5.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.
6.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.
7.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 and clients P&I.
8.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. Menu is posted in kitchen.
9.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 5 clients' medication.
10.Incidental Medical & Dental: All medications for clients are kept locked in a kitchen cabinet and inaccessible to other clients.
11.Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
12.Emergency Intervention: Residents at this facility do not have restraints nor do they require the use de-escalation techniques.
LPA conducted one (1) staff interviews during today’s visit. Two (2) client interviews were done, the other three clients were at their day programs.

Exit interview held and a copy of the report and provided to the Lead Staff Concepcion Pacania.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC809 (FAS) - (06/04)
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