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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601051
Report Date: 01/12/2026
Date Signed: 01/12/2026 12:31:28 PM

Document Has Been Signed on 01/12/2026 12:31 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: 6DATE:
01/12/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Concepcion Pacania, Lead Direct Support Professional TIME VISIT/
INSPECTION COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced required annual visit today. LPA met with Concepcion Pacania, Lead Direct Support Professional, and the reason for the visit was explained. Marilyn Acabal, Administrator, was informed about today’s visit telephonically but was unable to attend due to prior engagements. Concepcion Pacania, continued to facilitate today’s visit.

The facility is licensed to serve (6) adults, and Room #4 is approved for (2) non-ambulatory. The facility is operating within the scope of its license. Clients in care are provided services through the Eastern Los Angeles Regional Center. The single-story home is in a residential area of Temple City. The home consists of living and dining area, kitchen, (2) full bathrooms, (2) staff rooms, (3) shared resident bedrooms, attached garage, front and backyard.

During today's visit, the following was observed:

The facility is clean inside and out. All passageways, walkways, exits and ramps are free of debris and obstructions. There are no pools or large bodies of water. Living and dining area has sufficient seating for residents, and the furniture is in good repair. Kitchen was observed clean and refrigerator, range and small appliances are operable and in good repair. There is sufficient food for at least 2 days of perishables and 7 days of non-perishables. Cleaning supplies, sharps and medications are kept locked in kitchen cabinets. Three (3) resident bedrooms were observed and have sufficient lighting, the required furniture, and bedding supplies. Bedroom #4 has a bed with a half rail which is used by client #5; however, interview with staff indicated that there is no physician order in place for the half bed rail. The (2) bathrooms were inspected and were clean and sanitary. Bathrooms have grab bars and anti-skid mats. Water temperature was tested in each bathroom and measured 116.7 and 119.3 degrees F., which is within the required 105-120 degrees F. Carbon monoxide and smoke detectors were tested and found to be operating appropriately. The facility is equipped with two fire extinguishers, and both are kept charged and readily available for use.

***Continues on LIC 809-C***

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 01/12/2026 12:31 PM - It Cannot Be Edited


Created By: Mayra Cota On 01/12/2026 at 11:17 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(g)
85068.4 Acceptance and Retention Limitations: (g) If acceptance or retention of an individual 60 years of age or older... or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, licensee did not request from the department, an exception for clients over the age of 60 (client #1, #2,#4 and #5) which poses a potential risk to the health, safety, or personal rights of the persons in care.
POC Due Date: 01/26/2026
Plan of Correction
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Licensee/Administrator will submit an exception for any client over the age of 60 residing at the facility, with a family letter request, physician's report, and plan of care for each by POC due date 1/26/2026.
Type B
Section Cited
CCR
80072(a)(8)(E)
80072 Personal Rights (a)...each client shall have personal rights which include, but are not limited to, the following: (8) Not to be placed in any restraining device. Postural supports may be used under the following conditions: (E) Under no circumstances shall postural supports include tying of, or depriving or limiting the use of, a client's hands or feet.
1. A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed with prior licensing approval...


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in that client #5 has a half bedrail which does not have a physician's order on file which may pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2026
Plan of Correction
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Licensee/Administrator will submit a physician's order and request to the department for the half bed rail for client #5 by POC due date of 1/26/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2026


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: 01/12/2026
NARRATIVE
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Laundry appliances are kept in the garage and were observed to be in good repair. An overflow refrigerator is kept in the garage and was observed clean and stocked with additional food. Pantry in the garage has emergency water and food. The garage is kept clean and free of clutter. Backyard is clean and garden is well maintained.

LPA reviewed (6) resident and (4) staff files. File for client #5 did not contain physician order for half bed rail, and no age exception for clients over the age of 60 (C1, C2, C4 and C5) was in place. Safety drill records were also reviewed. The home conducts drills, quarterly. Last drill was conducted on 11/23/25 with staff and resident participation. The Emergency Disaster Plan was also reviewed and is up to date.

Medication is centrally stored in the kitchen and kept locked in medication cabinet. Medication review was conducted for (6) residents and found to be dispensed according to physician’s orders and documented accordingly.

Deficiencies were noted during today’s visit and citations issued per Title 22 Regulations. Exit interview was conducted with Hermocello Pacania, and a copy of this report, LIC 809-D and Appeal Rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2026
LIC809 (FAS) - (06/04)
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