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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004530
Report Date: 11/02/2021
Date Signed: 11/02/2021 12:34:05 PM

Unsubstantiated


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
07/30/2021 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210730140325
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:
11/02/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Abdul Arastoo, AdministratorTIME COMPLETED:
12:48 PM
ALLEGATION(S):
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-Resident not administered medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegation. LPA met with Administrator and explained the nature of the visit.

During the course of the investigation the following was conducted interviews with the following: Administrator, a review of the following: resident files, prescriptions and MAR records.

It is alleged that resident not administered medication as prescribed. Prescription and MAR sheet indicate that medication for Loxapine was to be given two capsules at morning and at bedtime by mouth. Records review indicates staff was following doctor’s orders as prescribed. Per interview conducted states medication was verified before giving the medication to C1, due to prescription originally being incorrect. There are no obvious

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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 2
Control Number 22-AS-20210730140325
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: 11/02/2021
NARRATIVE
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documentation errors to support that a violation has or has not occurred regarding medication. Based on the information available through record review and interviews, LPA is unable to corroborate or refute that a violation occurred as alleged as the information collected is conflicting.

Based on the information gathered during the investigation, interviews and review of all documents obtained, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

This report was reviewed with Administrator and a copy left at facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2