198601051-5-14-2024-28-AS-FFIS-D5L237-20240524170153

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601051
Report Date: 05/14/2024
Date Signed: 05/14/2024 11:56:44 AM

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

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230714145916

FACILITY NAME:	KEY WEST GUEST HOME, INC.		FACILITY NUMBER:	198601051
ADMINISTRATOR:	SHIRAZI, ALI ASGHAR		FACILITY TYPE:	735
ADDRESS:	10336 KEY WEST STREET		TELEPHONE:	(626) 444-0850
CITY:	TEMPLE CITY	STATE: CA	ZIP CODE:	91780
CAPACITY:	6	CENSUS: 6	DATE:	05/14/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Marilyn Acabal- Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility failed to submit an incident report to the proper agencies

INVESTIGATION FINDINGS:

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13

This licensing report supersedes the previous report dated 05/09/24. The reason it’s being superseded is to provide additional information not included on the original LIC9099 dated 05/09/24. The substantiated finding will remain the same.

Licensing Program Analyst (LPA) Sanjay Vaid and Licensing Program Manager Fernando Fierros conducted a subsequent complaint visit regarding the allegations listed above, LPA Vaid met with Lead Staff Concepcion Pacina and later during visit met with Administrator Marilyn Acabal, and discussed the purpose of the visit, investigation findings and to deliver the licensing report.

The investigation consisted of the following: On 07/18/2023 LPA Tao toured the physical plant, and obtained a copy of the client and staff roster, and client #1 file for review. LPA Tao conducted interviews with Assistant Administrator Marilyn Acabal, Staff #1 and Client #1 (C1).

See Continuation Page LIC9099C

Substantiated

Estimated Days of Completion: 0

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024

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 8

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 ASGHAR		FACILITY TYPE:	735
ADDRESS:	10336 KEY WEST STREET		TELEPHONE:	(626) 444-0850
CITY:	TEMPLE CITY	STATE: CA	ZIP CODE:	91780
CAPACITY:	6	CENSUS: 6	DATE:	05/14/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	??		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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8
9

Facility failed to designated a backup administrator

INVESTIGATION FINDINGS:

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2
3
4
5
6
7
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9
10
11
12
13

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 8

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: 05/14/2024

NARRATIVE

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This licensing report supersedes the previous report dated 05/09/24. The reason it’s being superseded is to provide additional information not included on the original LIC9099 dated 05/09/24. The substantiated finding will remain the same.

On todays visit, LPA Vaid and LPM Fierros conducted a tour of the physical plant along with Administrator, Marilyn Acabal and obtained a copy of staff roster and client roster. Client #2 was present and all five clients were attending day program during the visit.

On 05/09/24, LPA Vaid interviewed client #2(C2) and was unable to interview clients #3- #6 (C3-C6) due the clients attending day programs. Staff #1-staff #2 (S1-S2) were interviewed. LPA Vaid and S#1 toured the physical plant and LPA observed how staff interacted with facility clients. LPA requested and obtained a copy of the staff schedule and client roster.

Regarding the allegation: Facility failed to submit an incident report to the proper agencies. It is alleged that the facility failed to submit an incident report to the Regional Center (RC) and Community Care Licensing (CCL) for incident that occurred on 05/17/2023 regarding C#1 being sent to emergency room. The facility administrator stated to have faxed the incident report to Regional Center via fax and to Community Care Licensing via fax, however, the administrator was unable to produce the fax confirmations. To date, community care licensing has not received the 05/17/2023 incident report. The 05/17/2023 incident report dated 05/18/2023 was received by Regional Center on 06/26/2023, which is late reporting. The investigation revealed, the facility failed to submit the unusual incident report to Licensing per Title 22 Reporting Requirements, regarding the incident that occurred on or around 05/17/2023, where C1 was sent to the emergency room. Additionally, administrator failed to notify C1 Regional Center of the incident in a timely manner.

Based on LPAs interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview conducted with Administrator Marilyn Acabal, a copy of the licensing report and appeal rights were discussed and given at time of visit.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 8

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/14/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/14/2024 Section Cited CCR 80061(a)(1)(E)	1 2 3 4 5 6 7	Reporting Requirements(a) each licensee or applicant shall furnish to the licensing agency reports...(1)events reported shall include...(E)any unusual incident which threatens the physical or emotional health ofsafety of any client. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Cleared during visit. Administrator will train staff: protocols when faxing reports to licensing. POC by 05/13/2024.Recieved SIR on 05/09/24.
	8 9 10 11 12 13 14	Administrator failed to submit an unusual incident report to licensing per Title 22, reporting requirement, regarding an incident that occurred on or around 05/17/23, where C1 was sent to the emergency room. Additionally, administrator failed to notify C1 placement agency incident in a timely manner. C1 placement agency was notified on 06/26/2023.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/14/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 8

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 ASGHAR		FACILITY TYPE:	735
ADDRESS:	10336 KEY WEST STREET		TELEPHONE:	(626) 444-0850
CITY:	TEMPLE CITY	STATE: CA	ZIP CODE:	91780
CAPACITY:	6	CENSUS: 6	DATE:	05/14/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Marilyn Acabal- Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility failed to designated a backup administrator

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

This licensing report supersedes the previous report dated 05/09/24. The reason it’s being superseded is to provide additional information not included on the original LIC9099 dated 05/09/24. The findings will remain the same.

Licensing Program Analyst (LPA) Sanjay Vaid and Licensing Program Manager Fernando Fierros conducted a subsequent complaint visit regarding the allegation listed above, LPA Vaid met with Lead Staff Concepcion Pacina and later during visit met with Administrator Marilyn Acabal, and discussed the purpose of the visit, investigation findings and to deliver the licensing report.

The investigation consisted of the following: On 07/18/2023 LPA Tao toured the physical plant, and obtained a copy of the client and staff roster, and client #1 file for review. LPA Tao conducted interviews with Assistant Administrator Marilyn Acabal, Staff #1 and Client #1 (C1).

See Continuation Page LIC9099C

Unsubstantiated

Estimated Days of Completion: 0

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 6 of 8

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: 05/14/2024

NARRATIVE

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This licensing report supersedes the previous report dated 05/09/24. The reason it’s being superseded is to provide additional information not included on the original LIC9099 dated 05/09/24. The substantiated finding will remain the same.

On todays visit, LPA Vaid and LPM Fierros conducted a tour of the physical plant along with Administrator, Marilyn Acabal and obtained a copy of staff roster and client roster. Client #2 was present and all five clients were attending day program during the visit.

On 05/09/24, LPA Vaid interviewed client #2(C2) and was unable to interview clients #3- #6 (C3-C6) due the clients attending day programs. Staff #1-staff #2 (S1-S2) were interviewed. LPA Vaid and S#1 toured the physical plant and LPA observed how staff interacted with facility clients. LPA requested and obtained a copy of the staff schedule and client roster. Administrator Acabal provided LPA Vaid with the 05/17/2023 incident report..

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 a leave of absence. On 05/09/2024, LPA Vaid reviewed/obtained copies of staff files and staff schedules LIC 308 Designation of Facility Responsibility. The investigation revealed, per the LIC 308 dated 01/28/2008, the Licensee designated Administrator Marilyn Acabal as the authorized representative in their absence. Review of staffing schedules indicated Administrator Marilyn Acabal did not go on vacation during the months of May, June and July 2023. As indicated on the Designation of Facility Responsibility dated 07/15/2023, Licensee designated staff Mohammed R. Shirazi as the authorized representative in their absence. As indicated on the Designation of Facility Responsibility dated 07/26/2023, Licensee designated Administrator Marilyn as the authorized representative in their absence. LPA Vaid observed valid Administrator Certificate for Adult Residential Facility were issued to Administrator Marilyn Acabal, Staff Mohammed R. Shirazi and Licensee Ali A Shirazi, which were valid in 2022 through 2024. Administrator Marilyn Acabal was on vacation starting August 24, 2023 through September 12, 2023. During Administrator Marilynn Acabal’s leave of absence, Staff Mohammed Shirazi was designated as the authorized representative and Staff Shirazi’ Administrator certificate expired on 11/16/24. Additionally, Licensee Ali A Shirazi Administrator Certificate expires on 06/15/2024 and Administrator Marilyn Acabal Administrator Certificate expires on 11/18/2024. Therefore, there is no evidence to support that the facility failed to designate a back-up administrator in or around May of 2023.

See Continuation Page LIC9099C

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

LIC9099 (FAS) - (06/04)

Page: 7 of 8

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: 05/14/2024

NARRATIVE

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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, 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: 05/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

LIC9099 (FAS) - (06/04)

Page: 8 of 8