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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601051
Report Date: 05/09/2024
Date Signed: 05/22/2024 04:46:32 PM

Substantiated


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
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:
01:48 PM
MET WITH:Marilyn Acabal-AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to submit an incident report to the proper agencies
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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).

cont 9099C
Substantiated
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)
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