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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004530
Report Date: 10/19/2021
Date Signed: 10/19/2021 12:15:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/15/2021 and conducted by Evaluator Albert Marin
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210615102934
FACILITY NAME:PRIME CARE MANORFACILITY NUMBER:
306004530
ADMINISTRATOR:ABDUL ARASTOOFACILITY TYPE:
735
ADDRESS:8592 LAMPSONTELEPHONE:
(714) 534-4457
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:26CENSUS: 25DATE:
10/19/2021
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Administrator Abdul ArastooTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Client is sexually abusing another client.
Facility failed to provide a safe environment for clients
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility to deliver the investigation report for the complaint received on June 15, 2021. LPA met with Administrator (AD) Abdul Arastoo and stated the purpose of this visit and the allegations indicated in the complaint.

The Department investigated the the allegation that Client is sexually abusing another client. The following are the findings. Client 1 (C1) had been in the facility since 2017. On admission, C1 had a medical diagnosis of mental illness. Per interviews, C1 was not compliant with medications. In multiple undocumented occasions, C1 exhibited inappropriate behavior including giving out sexual comments and harassment towards female residents. Around June 1, 2021, C1 came in one of the female resident’s room, and attempted to have sexual contact with the occupant. The preponderance of evidence standard has been met. Thus, the allegation that client is sexually abusing another client is SUBSTANTIATED.

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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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 4
Control Number 22-AS-20210615102934
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PRIME CARE MANOR
FACILITY NUMBER: 306004530
VISIT DATE: 10/19/2021
NARRATIVE
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The Department conducted the investigation for the allegation that Facility failed to provide a safe environment for clients. The following are the findings. C1 had been in the facility since 2017. On admission, C1 had a medical diagnosis of mental illness. Per interviews, C1 was not compliant with medications. In multiple undocumented occasions, C1 displayed physically aggressive, or inappropriate behavior towards other clients in the community. The facility failed to provide documentation that these behavior episodes had been referred to client’s physician for appropriate level of care and management. Per file review, C1 violated several house rules of the facility on multiple occasions. The preponderance of evidence standards has been met, thus, the allegation that the facility failed to provide a safe environment for the clients is SUBSTANTIATED.

Deficiencies were observed. Citations were issued per Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted an exit interview with AD Arastoo. LPA discussed the report, deficiencies, citations, and appeal rights. LPA left copies of this report, 9099 D (Deficiency), appeal rights, and cited regulations in the facility.


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SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20210615102934
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PRIME CARE MANOR
FACILITY NUMBER: 306004530
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2021
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights. Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by:
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Administrator (AD) placed the client on a close watch to ensure the safety of other clients in care. Threat reduced. Administrator continued to check on other clients on the behavior of C1. AD was in regular consultation with case manager to address non-compliance with medication and to manage behavior. C1 was no longer in the facility. (continuation below)
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Based on investigation, the facility missed to provide clients with dignity in his/her personal relationships with other persons. Facility continued to keep Client 1(C1) even after receiving reports of aggression and inappropriate behavior towards other clients. This posed immediate threat on personal rights and safety of clients in care.
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AD will continually monitor other clients in care and address their behavior accordingly.

Plan of correction accepted. Citation was cleared on this visit.

LPA provided AD with copy of the cited regulations for full reference.
Type A
10/20/2021
Section Cited
CCR
85075.4(c)
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85075.4 Observation of the Client. The licensee shall bring observed changes, including but not limited to unusual weight gains or losses, or deterioration of health condition, to the attention of the client's physician and authorized representative, if any. This requirement was not met as evidenced by:
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AD placed C1 on close watch; and continually followed up with other clients in care. Threat reduced. AD directed staff to report to AD all unusual observation on the clients. AD started to document all referrals made to their attending physicians and responsible parties. Plan of correction accepted. Citation cleared during the visit.
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Based on investigation, the facility missed to bring observed changes to the attention of the client’s physician and authorized representative. The facility did not provide documentation on C1's non-compliance with medications, and behavior issues to C1's physician and authorized representative. This posed immediate threat on the health and safety of clients in care.
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LPA provided AD with copy of the regulation for full reference.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 22-AS-20210615102934
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PRIME CARE MANOR
FACILITY NUMBER: 306004530
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2021
Section Cited
CCR
80061(d)
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80061 Reporting Requirements. Any suspected physical abuse that does not result in serious bodily injury of an... dependent adult shall be reported to the local ombudsman,... licensing agency, and the local law enforcement agency within 24 hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not met as evidenced by:
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AD will provide training to staff on reporting requirements and on reporting about allegations of any forms of abuse as indicated in the Welfare and Institutions Code. Threat reduced. AD will provide copy of the attendance on training to Orange County Regional Office on or before November 5, 2021.
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Based on investigation, the facility failed to report the suspected physical abuse of a dependent adult to concerned agencies within 24 hours from its occurrence. The facility did not make any report on the alleged sexual abuse to any of the above agency. This posed immediate threat on the safety of clients in care.
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LPA provided copy of the cited regulations to AD for full reference.
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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.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4