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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004530
Report Date: 09/01/2022
Date Signed: 09/01/2022 12:10:07 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
08/16/2022 and conducted by Evaluator Albert Marin
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220816160258
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: 24DATE:
09/01/2022
UNANNOUNCEDTIME BEGAN:
10:26 AM
MET WITH:Administrator Abdol Arastoo TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility did not provide fans for clients in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility to deliver findings for the complaint received last August 16, 2022.

On allegation that facility did not provide fans for clients in care, the following are the findings. During August 23, 2022 unannounced initial investigation visit, LPA observed that the thermostat in Building A was set at 80 F and 79F in Building B. Temperature in client's rooms were recorded between 77.5 to 81.3 F Per interviews, clients bought their own electric fan for own use. Thus, the allegation is substantiated.

Deficiency was observed; and citation was issued per Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted an exit interview with AD. LPA discussed the findings, citations, and appeal rights. Copies of this report, LIC9099 D, civil penalty assessment form, and regulations cited were left in the facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
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-20220816160258
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: 09/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/02/2022
Section Cited
CCR
80072(a)(2)
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80072 Personal Rights. To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by:
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As plan of correction, Administrator will check with clients who needs an electric fan; and will provide them as needed. AD will ensure that the air conditioning unit is good working conditions at all time. AD showed two standby electric fan units are available for client use. AD will provide proof of correction to CCLD on 09/28/2022
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Based on observation, interviews and file review, the facility did not accord comfortable accommodations, and equipment to meet clients' needs. Facility did not provide electric fans in client's rooms to meet clients' needs for comfortable accommodations specially during high temperature weather. This poses potential threat on personal rights of clients in care.
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Civil Penalty - Repeat Violation was assessed.

Copy of the cited CCR section was provided for full reference.
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Notes://///

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: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
08/16/2022 and conducted by Evaluator Albert Marin
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220816160258

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: 24DATE:
09/01/2022
UNANNOUNCEDTIME BEGAN:
10:26 AM
MET WITH:Administrator Abdol ArastooTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
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Staff did not intervene clients from engaging in inappropriate behaviors.
Facility showers have no hot water.
Facility air conditioning is not working.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marin made an unannounced visit to this facility to deliver findings for the complaint received last August 16, 2022.

On allegation that staff did not intervene clients from engaging in inappropriate behaviors, the following are the findings. Per observation and interview, Client 1 had behavior issues which included engaging in inappropriate behavior towards opposite sex. There had been instances wherein Client 1 made inappropriate verbal exchanges with other clients, All witnesses interviewed denied observing physical advancement from Client 1. 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, above allegation is deemed UNSUBSTANTIATED.

please see next page.

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

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20220816160258
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: 09/01/2022
NARRATIVE
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On allegation that facility showers have no hot water, the following are the findings. During the August 23, 2022 unannounced investigation visit, LPA measured hot water in common bathrooms. Hot water in Building A was measured at 111.9 F and hot water in Building B was 118.4 F. Per interviews, witnesses stated that they had no concerns with the hot water in the bathroom. Thus the above allegation is deemed UNSUBSTANTIATED.

On allegation that facility air conditioning is not working, the following are the findings. During the August 23, 2022 unannounced investigation visit, LPA measured the temperature outside the facility between 72 and 73.7 F. LPA then checked the temperature in random client’s room and temperature ranged from 77.5 F to 81.3 F. Thermostat setting for Building A had a reading of 76 F and set to give cool air at 80F. Thermostat in Building B had a temperature reading of 76 F and set to turn on at 79F. All thermostat units are located in the hallways. Per Administrator’s statement, circuit breaker was tripped off few weeks back, but was immediately addressed. Thus the allegation that facility air conditioning is not working is deemed UNSUBSTANTIATED.

LPA Marin conducted an exit interview with AD and copy of this report was left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4