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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602614
Report Date: 05/04/2024
Date Signed: 05/04/2024 02:47:58 PM

Document Has Been Signed on 05/04/2024 02:47 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:PRIME OPTIONS CARE INCFACILITY NUMBER:
198602614
ADMINISTRATOR/
DIRECTOR:		NGUYEN, HAIFACILITY TYPE:
735
ADDRESS:2041 W 162ND STTELEPHONE:
(310) 678-6784
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 5CENSUS: 4DATE:
05/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:41 PM
MET WITH:Hai Nguyen-LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:47 PM
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On 5/4/24 Licensing Program Analysts (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPAs met with Hai Nguyen/Licensee and the purpose of today’s visit was explained. The facility is licensed to operate for (5) non-ambulatory developmentally disabled or Mentally Ill adults ages 18 through 59 ambulatories only. Currently, the home has (4) clients. The clients are from: Harbor Regional Center. (0) Clients have Restricted Health Care Conditions, and (0) are utilizes postural support or protective devices. Staff to client ratio is (1:2).

The facility is a single-story structure located in a residential neighborhood. It consists of the following: 5 bedrooms, 2 bathrooms, family room/dining room, kitchen, living room, shaded area, indoor and outdoor activity area, laundry room and an attached garage.

LPA Iniguez and administrator toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. The shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105F°-120F° degrees (Kitchen 113.5F°, Bathroom #1 107.8°F).

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PRIME OPTIONS CARE INC
FACILITY NUMBER: 198602614
VISIT DATE: 05/04/2024
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LPA Iniguez observed the facility clean, sanitary, and appropriately furnished at the time of the visit. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. Carbon monoxide/Smoke detectors were observed and operational. Fire extinguishers were fully charged, toxins and knives were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last facility disaster drill was:4/1/24. LPA reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit.

A total of (3) clients records and (3) staff records and (3) Medication Administration Records (MARs) LPAs found no discrepancies at the time of the visit. Facility licensee fees are current.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.


An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Hai Nguyen/Licensee.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2024
LIC809 (FAS) - (06/04)
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