198600536-6-12-2023-28-AS-KRAZ-CSR465-20230612184858

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600536
Report Date: 06/12/2023
Date Signed: 06/12/2023 06:50:08 PM

Document Has Been Signed on 06/12/2023 06:50 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	SIERRA GUEST HOME		FACILITY NUMBER:	198600536
ADMINISTRATOR:	SHIRAZI, ALI ASGHAR		FACILITY TYPE:	735
ADDRESS:	5039 FIESTA AVENUE		TELEPHONE:	(626) 309-9266
CITY:	TEMPLE CITY	STATE: CA	ZIP CODE:	91780
CAPACITY:	6	CENSUS: 4	DATE:	06/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Marilyn Acabal		TIME COMPLETED:	01:30 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 06/12/2023 at 9:00 am. LPA was met by Staff 1 (S1) and explained the purpose of the visit. Administrator Marilyn Acabal assisted in tour of facility. Facility is licensed to serve clients 18 to 59 years old. The facility has a fire clearance approved for four (4) non-ambulatory. There are four (4) level 4C developmentally disabled clients residing at this facility. Clients at this facility are receiving services from East Los Angeles Regional Center. LPA requested and obtained a copy of Personnel Report, and Resident Roster.

LPA OBSERVATIONS: Tour began at 9:11 am and was led Administrator Acabal. The facility is a single-story building located in a residential area with three (3) client bedrooms, one (1) staff office, two (2) bathrooms, kitchen, dining room, front yard, backyard and detached garage.

· Front Yard: Was clean and well maintained. No hazards were observed.

· Kitchen: LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7-day supply on non-perishables. At 9:0 am, LPA observed knives and sharps located in nearby cabinet to be inaccessible to 4 out of 4 clients in care. LPA observed several bottles of cleaning solutions and disinfectants under kitchen sink cabinet to be inaccessible to 4 out of 4 clients in care.

· Dining Room/Living room: Dining room was observed to be clean and contained one table and chairs. Living room was observed to contain 2 sofas, 1 recliner and contained plenty of lighting. LPA observed nearby thermostat located on living room wall to read 72 degrees F. LPA observed Client #1 (C1) was wearing a protective device while sitting in living room area. LPA could not find exception letter granting approval for protective devices for C1.

· Linen Closet: Contained plenty linens, towels, and hygiene products.

· Client Rooms 1 - 3: All contained the required furnishings, linens and were observed to be clean with plenty of closet space. bedroom #2 and bedroom# 3 are currently private.

SEE 809-C for continuation...

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

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

LIC809 (FAS) - (06/04)

Page: 1 of 3

Document Has Been Signed on 06/12/2023 06:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SIERRA GUEST HOME	FACILITY NUMBER: 198600536
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80072(F)

80072 PERSONAL RIGHTS (F) Protective devices including, but not limited to, helmets, elbow guards, and mittens which do not prohibit a client's mobility but rather protect the client from self-injurious behavior are not to be considered restraining devices for the purpose of this regulation. Protective devices may be used if they are approved in advance by the licensing agency as specified below. 1. All requests to use protective devices shall be in writing and include a written order of a physician indicating the need for such devices. The licensing agency shall be authorized to require additional documentation including, but not limited to, the Individual Program Plan (IPP) as specified in Welfare and Institutions Code Section 4646, and the written consent of the authorized representative, in order to evaluate the request. 2. The licensing agency shall have the authority to grant conditional and/or limited approvals to use protective devices. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 1 clients, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/26/2023
	Plan of Correction
1 2 3 4	Licensee will request exception for use of protective devices by POC due date. Request must be submitted to LPA via email. Licensee will submit written oder from physician indicating need for device, most recent IPP, and written consent from authorized representative, requesting the exception.

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: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SIERRA GUEST HOME	FACILITY NUMBER: 198600536
	VISIT DATE: 06/12/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

· Bathrooms: Shared client bathroom# 1 was observed to be clean and contained soap and paper towels. Signs promoting hand washing were observed. Water temperature in this bathroom was measured at 114.6 degrees F which is in the required 105 – 120 degrees F. Bathroom #2 located in client bedroom #3, was observed to be clean and water temperature was measured at 113.8 degrees F.

· Centrally Stored Medications: LPA observed cabinet located in kitchen to be locked and inaccessible to residents. LPA reviewed 4 client medications and Medication Administration Record (MAR).

· Backyard: Clean and free from hazards. LPA observed plenty of seating and shade. No large bodies of water were observed.

LPA observed carbon monoxide in hallways. Smoke detector is hard wired and tested during visit. Administrator certificate was observed for Marilyn Acabal with an expiration date of 06/15/24. Last fire drill was conducted on 04/17/23 and last earthquake drill was conducted on 04/11/23. First Aid kit was inspected. 4 out of 4 clients records were reviewed. Staff files were reviewed.

Deficiencies are being cited during visit. Exit interview was conducted with Staff S1 and a copy of this report, LIC 809-D, and appeals rights was provided via email due to printer problems.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3