306004530-4-6-2022-22-AS-AMAN-CD8RY9-20220406132559

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 04/06/2022
Date Signed: 04/06/2022 01:26:04 PM

Document Has Been Signed on 04/06/2022 01:26 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	PRIME CARE MANOR		FACILITY NUMBER:	306004530
ADMINISTRATOR:	ABDOL ARASTOO		FACILITY TYPE:	735
ADDRESS:	8592 LAMPSON AVENUE		TELEPHONE:	(714) 534-4457
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY: 26		CENSUS: 25	DATE:	04/06/2022
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	12:22 PM
MET WITH:	Administrator Abdul Arastoo		TIME COMPLETED:	01:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Albert Marin made an unannounced plan of correction visit in this facility LPA met with Administrator (AD) Abdul Arastoo; and stated the purpose of the visit.

During the required annual inspection initiated last February 25, 2022 and completed on March 10, 2022, deficiencies were observed, and citations were issued per Title 22 Division 6 of the California Code of Regulations (CCR):

CCR 80076(a)(1): February 25, 2022 visit, LPAs observed a unopened cauliflower package with formation consistent with molds was observed in the refrigerator. AD discarded the cauliflower. Immediate threat was reduced. As plan of correction the facility will assign a person to do a weekly check of the supply and ensure that they are in good quality. Facility will provide proof of written instruction to the staff and copy of the inspection. AD will provide proof of correction by March 25, 2022 - Proof of correction received by due date. Deficiency cleared by this visit.

CCR 80076(a)(14): On February 25, 2022 visit, LPAs observed uncovered food items left in the refrigerator. AD discarded the uncovered food items. Immediate threat was reduced. As plan of correction, facility will ensure all food items kept in the refrigerator and freezer are covered. Facility will create a daily temperature log for refrigerator and freezer. Facility will create cleaning schedule for freezer an refrigerator and log completed task. Documents and log reviewed during this visit. Deficiency cleared.

CCR 80072(a)(2): : On February 25, 2022 visit, LPAs observed that Client's personal belongings were scattered on the floor and room was shared with another client. AD directed staff to remove and clean up Room 2A. Immediate threat was reduced. As plan of correction, AD will review the needs and services plan of the client and address issues on hand. AD will document that cleanliness of the room is monitored. LPA inspected the room during this visit - Deficiency cleared.

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SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PRIME CARE MANOR	FACILITY NUMBER: 306004530
	VISIT DATE: 04/06/2022

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CCR 80087(a): Common areas including bathrooms and kitchen were found with dust and grease. As plan of correction, facility will schedule create schedule for deep cleaning of all common bathrooms and log. And maintain sanitary environment at all times. AD will do deep cleaning of the bathrooms. Correction was observed during this visit - Deficiency cleared.

CCR 80065(a): AD immediately reminded staff to ensure all clients are accounted for at all times. Immediate threat reduced. As plan of correction AD will give training to staff and documents of meeting with clients reviewing the house rules specifically in going out and coming back of the facility. Correction was observed during this visit. - Deficiency cleared.

CCR 85088(c)(A): As plan of correction, Facility will provide clean linens in good repair and in amount sufficient to cover the bed and allow change at least a week or as necessary. AD will provide additional sheets for use of clients. Correction was observed during this visit. Facility replaced washer unit. Deficiency cleared.

CCR 85088(c)(1): As plan of correction, facility will ensure that all the beds are maintained clean and in good repair. AD will replace the mattress of Client 1. Correction was observed during the visit - Deficiency cleared.

LPA Marin conducted an exit interview with AD Arastoo; and copy of this report and letters of deficiency cleared were left in the facility.

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SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

LIC809 (FAS) - (06/04)

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