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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 10/19/2021
Date Signed: 10/19/2021 12:21:07 PM

Document Has Been Signed on 10/19/2021 12:21 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 MANORFACILITY NUMBER:
306004530
ADMINISTRATOR:ABDUL ARASTOOFACILITY TYPE:
735
ADDRESS:8592 LAMPSONTELEPHONE:
(714) 534-4457
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 26CENSUS: 25DATE:
10/19/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator Abdul ArastooTIME COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility, to conduct case management. LPA met with AD Abdul Arastoo and stated the purpose of this visit.

During the investigation of Complaint No. 22-AS-20210615102934 received against, per interviews and file review, Staff 1 (S1) and Staff 2 (S2) were not associated to the facility; and were not part of the Licensing Information System Personnel Summary Report printed on June 15,2021 for the facility.

On October 5, 2021, LPA Marin received a email from AD Arastoo providing documentation that the facility submitted a clearance transfer request For Staff 2 (S2). The document had a date stamped that it was received by Community Care Licensing Division (CCLD) last May 18, 2018. Facility was not able to provide supporting document on the clearance transfer request for Staff 1.

For this visit, the deficiency had been observed and a citation was issued per Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted an exit interview with AD Arastoo. LPA discussed the deficiency, citation, and appeal rights. LPA left copies of this report, LIC 809 (Deficiency), appeal rights and cited regulations in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2021
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 10/19/2021 12:21 PM - It Cannot Be Edited


Created By: Albert Marin On 10/19/2021 at 08:21 AM
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: 10/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2021
Section Cited
CCR
80019(e)(2)

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80019 Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 80019(f)…This requirement was not met by:
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AD and LPA checked the clearance status of Staff 1 (S1). S1 has an active working clearance. Threat reduced. AD established account with the Guardian system and will be using the system to regularly check the clearance and maintain up to date association of individuals to the facility. Plan of correction accepted. Citation cleared during the visit.
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Based on file review, the Facility failed to request transfer of criminal background of Staff 1. AD was not able to provide supporting documents that transfer request was completed for S1 prior to this investigation. to the facility. This posed an immediate threat on the safety of residents in care.

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LPA provided copy of the regulation to AD for full reference.

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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:Luz Adams
LICENSING EVALUATOR NAME:Albert Marin
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2021


LIC809 (FAS) - (06/04)
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