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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 02/02/2024
Date Signed: 02/02/2024 04:27:53 PM

Document Has Been Signed on 02/02/2024 04:27 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PRIME CARE MANORFACILITY NUMBER:
306004530
ADMINISTRATOR:ABDOL ARASTOOFACILITY TYPE:
735
ADDRESS:8592 LAMPSON AVENUETELEPHONE:
(714) 534-4457
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 26CENSUS: 25DATE:
02/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:TIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility to conduct an unannounced Required 1-Year Inspection. LPA was greeted and granted entry by Daizy Munez, Caregiver. The Administrator Abdul Arastoo joined the inspection approximately 20 minutes after LPA's arrival. The facility is comprised of two buildings. Building A is a one-story building. Building A houses five client rooms, three bathrooms, kitchen, dining room and staff office. Building B is a one-story building. Building B houses eight client rooms, three bathrooms and laundry area.
All residents rooms had required elements, including bed, chair, closet space and ample lighting. Facility has extra linens for clients in hallway cabinets. Restrooms are stocked with soap and paper towels. Hot water in the Building B bathrooms measured at 105 degrees Fahrenheit, 109.6 degrees Fahrenheit and 110 degrees Fahrenheit. The hot water heater for Building A received its annual service on Monday, January 30, 2024. The hot water heater was functional prior to the plumber cleaning it. After the clean, the plumber realized the hot water heater stopped producing hot water. Administrator stated they ordered parts for the repair and they will be arriving at the facility by February 6, 2024 at which point the Administrator will coordinate with the plumber to repair the hot water heater. For the time being, all residents are using the showers in Building B, however Building A toilets and sinks are still functional for Building A residents. LPA observed facility has emergency food and water supply. LPA observed knives to be locked up in the kitchen. Toxins and chemicals are locked up in a closet in Building B. Medication for each resident is kept locked in the staff office. The backyard has a shaded seating area. LPA reviewed client files, staff files, medication and P&I. LPA interviewed three clients.
LPA issued two technical violations for the following: Infection Control - 85095.5(c) adn Physical Plant & Environmental Safety - 80087(a)

Based on the observations made during today's visit, one deficiency is being cited as per Title 22 Division 6 Chapter 2 of the California Code of Regulations. An exit interview was conducted with Administrator Abdul Arastoo and a copy of this report, deficiency page, LIC9102s and appeal rights were provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2024
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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Document Has Been Signed on 02/02/2024 04:27 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 02/02/2024 at 03:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PRIME CARE MANOR
FACILITY NUMBER: 306004530

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(b)
Building and Grounds
(b) All clients shall be protected against hazards within the facility through provision of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the facility backyard. LPA observed a fence in teh backyard separating the facility from a property next door. LPA observed part of this fence to be rusted and topped with rusted barbed wire on it. The fence is accessible to clients in care which poses a potential safety risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Administrator stated they will repair and/or remove parts of the rusted portion of the fence. Administrator stated they will extend the unrusted portion of the fence to maintain separation from the neighnoring property. Administrator stated that by the assigned POC due date of 02/16//2024 they will send LPA via email a photo of the fence once repairs and/or removal is completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024


LIC809 (FAS) - (06/04)
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