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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601051
Report Date: 09/05/2024
Date Signed: 09/05/2024 10:49:08 AM

Document Has Been Signed on 09/05/2024 10:49 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: DATE:
09/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Direct Staff Person, Concepcion PacaniaTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) S Vaid conducted an unannounced case management visit to ascertain information noted on semi -annual residential visit conducted by the Eastern Los Angeles Regional Center on 04/29/24, regarding medication dispensation. LPA met with and interviewed Concepcion Pacania, DSP(Direct Staff Person) who was advised of the visit.

During the visit LPA reviewed clients medications and MAR(Medication Administration Record) no deficiencies were noted. An error occurred with R1 while they were out with their family. Family of R1 had dropped the medication and had informed the facility of the misplaced medication. The facility immediately notified the physician and reordered the medication before R1 return to the facility.

A tour of the physical plant was conducted. The following deficiencies were corrected: Living room sliding screen was replaced. The facility has had the interior repainted, broken blinds were replaced. Disaster plan outlining actions taken during emergency and safety drills conducted monthly were reviewed. The food is ordered weekly as needed, LPA observed food requirements normal.

Therefore, deficiency will be issued for the physical environment. Per Title 22 Regulations, the deficiencies are cited on 809D.

Exit interview was conducted and copy of report and appeals was left at facility.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2024
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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Document Has Been Signed on 09/05/2024 10:49 AM - It Cannot Be Edited


Created By: Sanjay Vaid On 09/05/2024 at 10:31 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: 09/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2024
Section Cited
CCR
80088(b)

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80088 Furniture, Fixtures, Equipment, and Supplies,
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.
Title 22, Division 6. Chapter 1. Article 07. Physical Environment
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Defiencies were cleared during visit.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Fernando Fierros
LICENSING EVALUATOR NAME:Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024


LIC809 (FAS) - (06/04)
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