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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 11/04/2021
Date Signed: 11/04/2021 01:33:09 PM

Document Has Been Signed on 11/04/2021 01:33 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:
11/04/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator Abdul Arastoo TIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Marin made an unannounced case management visit. LPA met with Administrator Abdul Arastoo; and stated the purpose of this visit.

During the investigation for the complaint no. 22-NP-20210928154650 that was received last September 28, 2021 against the facility, LPA observed the following: On the September 29, 2021 incident, Client 1 was transported to the hospital for further evaluation. LPA did not receive any form of information that responsible person was informed about the hospital transfer. Responsible person only received a phone call that Client 1 was ready to be discharged from the hospital.

On this visit, LPA Marin issued the citation per Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted an exit interview with AD Arastoo. LPA discussed the deficiencies, citation and appeal rights. Copies of this report, Deficiency page, Advisory Notes, appeal rights and cited regulations were left in the facility.
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.

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Document Has Been Signed on 11/04/2021 01:33 PM - It Cannot Be Edited


Created By: Albert Marin On 11/04/2021 at 08:50 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: 11/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2021
Section Cited
CCR
85072(b)(2)

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 85072 Personal Rights. The licensee shall insure that each client is accorded the following personal rights. To have the facility inform his/her relatives and authorized representative, if any, of activities related to his/her care and supervision… This requirement was not met as evidenced by
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As plan of correction, AD will inform the family member and other authorized representative. Immediate threat was reduced. AD will provide training to staff about relaying reports to authorized representatives. AD will submit proof of training on Community Care Licensing Division (CCLD) on or before November 18, 2021.
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Based on investigation, the facility missed to inform client's authorized representative about activities related to client's care and supervision. On 9/19/21, facility did not inform C1's relative about the incident that led to C1 being transported to the hospital for further evaluation. This posed immediate threat on personal rights of resident in care.
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Copy of cited regulation section was provided 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: 11/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2021


LIC809 (FAS) - (06/04)
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