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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004530
Report Date: 11/04/2021
Date Signed: 11/04/2021 12:53:17 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
09/28/2021 and conducted by Evaluator Albert Marin
PUBLIC
COMPLAINT CONTROL NUMBER: 22-NP-20210928154650
FACILITY NAME:PRIME CARE MANORFACILITY NUMBER:
306004530
ADMINISTRATOR:ABDUL ARASTOOFACILITY TYPE:
735
ADDRESS:8592 LAMPSONTELEPHONE:
(714) 534-4457
CITY:GARDEN GROVESTATE: ZIP CODE:
92841
CAPACITY:26CENSUS: 25DATE:
11/04/2021
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator Abdul ArastooTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Facility failed to provide adequate care and supervision that resulted to physical injuries to a client in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility to deliver the findings for the investigation completed for complaint that was received on September 28, 2021 against the facility.

On allegation that facility failed to provide adequate care and supervision that resulted to physical injuries to a client in care, the following are the findings. Based on file review, observation and interviews, about a month prior to the incident, Client 1 (C1) exhibited unprovoked aggression towards non-facility staff and other facility clients in three separate occasions. Police had been involved or C1 was referred to the hospital for further management. On September 19, 2021 about 4:30 PM after dinner was served, Staff 1 and some clients were out in the patio. It was a sudden event that C1 had an argument with another client and resulted to a brief physical aggression. Staff observed the incident. After both clients calmed down, Client 1 was observed to have called the police; and moments after they arrived in the facility. Police talked to both clients. Paramedics arrived and took Client 1 to the hospital for further evaluation. Client was released about 8:30 PM with final diagnosis of Assault, Facial Pain and Elbow Sprain, left. (Page 1/2)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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-NP-20210928154650
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: 11/04/2021
NARRATIVE
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Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation that facility failed to provide adequate care and supervision that resulted to physical injuries to a client in care is deemed UNSUBSTANTIATED.

LPA Marin conducted an exit interview with AD Abdul Arastoo and copy of this report was left in the facility.

(Page 2/2)
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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