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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601051
Report Date: 05/09/2024
Date Signed: 05/09/2024 01:40:20 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
07/14/2023 and conducted by Evaluator Sanjay Vaid
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230714145916
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:
05/09/2024
UNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Concepcion Pacina- Lead StaffTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility failed to designated a backup administrator
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sanjay Vaid conducted a subsequent complaint visit regarding the allegations and discuss the findings of the complaint investigation. LPA Vaid met with Concepcion Pacina -lead staff and Marilyn Acabal- administrator to discuss the purpose of the visit, which was to deliver complaint investigation findings.

The investigation consisted of the following: On 07/18/2023 LPA Tao toured the facility, conducted physical plant tour of the facility, and obtained a client and staff roster, file for client #1 for review.

On 07/18/2023 the department conducted interviews with Assistant Administrator -Marilyn Acabal and lead staff – Concepcion Pacania. On 07/18/2024 the department conducted interview with client #1 (C1).

Con't 9099C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 28-AS-20230714145916
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: KEY WEST GUEST HOME, INC.
FACILITY NUMBER: 198601051
VISIT DATE: 05/09/2024
NARRATIVE
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Regarding the allegation: facility failed to designate a backup administrator. It is alleged that the facility failed to designate a back-up administrator when the administrator is on leave of absence. Based on the facility files collected and reviewed on 05/09/2024, revealed that the administrator/Licensee had designated the assistant administrator at the be their replacement in the event of administrator is absent due to vacation or emergency leave, dated 01/28/2008. Further review and inspection of records reveal that the designated responsibility was documented should the current administrator goes on leave of absence, a replacement has been designated to oversee the facility responsibilities dated 07/15/2023.

Therefore, there is no evidence to support that the facility failed to designate a back-up administrator.

Based upon record review and interviews conducted the findings indicate that, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, there fore the allegation is unsubstantiated.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20230714145916
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: KEY WEST GUEST HOME, INC.
FACILITY NUMBER: 198601051
VISIT DATE: 05/09/2024
NARRATIVE
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Regarding the allegation: facility failed to designate a backup administrator. It is alleged that the facility failed to designate a back-up administrator when the administrator is on leave of absence. Based on the facility files collected and reviewed on 05/09/2024, revealed that the administrator/Licensee had designated the assistant administrator at the be their replacement in the event of administrator is absent due to vacation or emergency leave, dated 01/28/2008. Further review and inspection of records reveal that the designated responsibility was documented should the current administrator goes on leave of absence, a replacement has been designated to oversee the facility responsibilities dated 07/15/2023.

Therefore, there is no evidence to support that the facility failed to designate a back-up administrator.

Based upon record review and interviews conducted the findings indicate that, although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, there fore the allegation is unsubstantiated.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20230714145916
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: KEY WEST GUEST HOME, INC.
FACILITY NUMBER: 198601051
VISIT DATE: 05/09/2024
NARRATIVE
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On todays visit, LPA attempted to interview client #2(C2) they are non-verbal, clients #3- #6(C3-C6) are at their day programs and were not interviewed, and staff #1-staff #2 (S1-S2). Staff #3-#9(S3-S9) were not scheduled to work at the time of visit. Toured the physical plant with lead staff C#1 and observed how staff interact with facility client. Administrator arrived shortly after, LPA requested and obtained a copy of the staff schedule and client roster.

Regarding the allegation: facility failed to designate a backup administrator. It is alleged that the facility failed to designate a back-up administrator when the administrator is on leave of absence. Based on the facility files collected and reviewed on 05/09/2024, revealed that the Licensee S#4 had designated the administrator S#2 their replacement, dated 01/28/2008. S#2 did not go on vacation during the months of May, June and July. Further review and inspection of records reveal that the designated responsibility was documented should the current administrator goes on leave of absence, a replacement has been designated to oversee the facility responsibilities dated 07/15/2023. S#2 took vacation in August 24, to September 12, 2023. S#3 was designated as the replacement during S#2's absence. Administrator certificate for S#4 expires 06/15/2024, C#2 certificate expires 11/18/2024 and certificate for C#3 expires 11/16/2024. Schedule for May 2023, 24-hour staff scheduled shows S#2 on duty Monday- Friday 10am to 2pm. Schedule for August 2023 and September 2023 show S#3 covering for S#2. Therefore, administrator coverage for the facility was provided throughout the period in question, there is no evidence to support that the facility failed to designate a back-up administrator.

Based upon record review and interviews conducted the findings indicate that, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted with Marilyn Acabal, Administrator. A copy of the licensing report was provided at time of visit.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4