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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 02:05:03 PM

Document Has Been Signed on 11/04/2021 02:05 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 - Health ChecksUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Abdul Arastoo TIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Marin made an unannounced case management visit. LPA met with Administrator (AD) Abdul Arastoo; and stated the purpose of this visit. The purpose of this visit is to continue the case management conducted last November 2, 2021.

On the initial visit, LPA Albert Marin and LPA Jerome Haley conducted a physical tour of the facility that included but not limited to Building A (structure close to the street / main entrance), Building B, and facility grounds. Building A have the common dining area, office and medication room, kitchen, clients rooms and common bathrooms. Building B have common bathrooms, laundry area, patio and client's rooms.

The following were the initial observations: LPAs Marin and Haley that there was only one staff on the floor. Lunch service was completed, and staff was in the kitchen doing dinner meal preparation. LPAs observed that the kitchen was in order; facility met the minimum two day perishable and seven day nonperishable food stock requirements; and menu plan posted. At 11:32 AM, LPAs observed about 14 pieces of persimmon in a bowl and did not observe any other fruits available. When AD Arastoo arrived in the facility about 15-20 minutes after receiving the call, LPAs started the tour with AD Arastoo. In Room A2, LPAs observed a broken light switch cover. About 11:45 AM LPAs and verified with AD, Building A did not have a Carbon monoxide (CO) detector in place; one of two common bathrooms had a broken shower wall and with black discoloration towards its lowest portion. LPAs did not observed any soap or paper towel. The facility had a centralized fire alarm system. The central panel is located in Building A. LPAs randomly observed that the ceiling sensors were lit green. LPA Marin requested a copy of the latest fire inspection on the system from AD Arastoo. AD agreed to provided Community Care Licensing Division with a copy on or before 5:00 PM of November 18, 2021.

The tour continued to Building B. At 11:53 AM, LPAs Marin and Haley observed and verified with AD, there were two CO detectors place on the wall but were not in working conditions. All three common bathrooms did not have soap and paper towels; and one was observed to be stained. (Page 1)
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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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: 11/04/2021
NARRATIVE
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For this visit, LPA Marin issued citations per Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted an exit interview with AD Arastoo. LPA discussed the deficiencies, citations, advisory notes and appeal rights to AD. Copies of this report, deficiencies, advisory notes, appeal rights and cited regulations were left in the facility.

(Page 2)
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
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 11/04/2021 02:05 PM - It Cannot Be Edited


Created By: Albert Marin On 11/04/2021 at 10:29 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
HSC
1503.2

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1503.2 Carbon monoxide detectors required; inspection. Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility ... The department shall account for the presence of these detectors during inspections. This requirement was not met as evidenced by:
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AD will install and/or replace the Carbon monoxide detector in each building. Immediate threat reduced. AD will ensure that all detectors are in good working conditions at all times. Proof of correction will sent to Community Care Licensing Division on or before November 8, 2021.
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Based on observations, the facility failed to maintain working carbon monoxide detectors in the facility. As verified with AD, there was no Carbon monoxide (CO) detector in Building A and two CO detectors in Building B were not in working conditions. This posed immediate threat on the safety of clients in care.
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Type A
11/05/2021
Section Cited
CCR85088(c)(5)

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85088 Fixtures, Furniture, Equipment and Supplies. The licensee shall ensure provision to each client ... supplies necessary for personal care and maintenance of personal hygiene...nonmedicated soap, toilet paper... This requirement was not met as evidenced by
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AD will provide the necessary hygiene materials are readily available at all times. Immediate threat reduced. AD will ensure that supply and other bathroom fixtures are in good working conditions at all times. AD will send proff of correction to CCLD on or before November 18, 2021.
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Based on observation and interviews, licensee failed to ensure supply necessary for personal care and maintenance of personal hygiene. As verified with AD, all common bathrooms did not have nonmedicated soap and paper towels for use of clients. This posed immediate threat on the health of clients in care.
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Copy of regulation section had been proved to AD for full reference.
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


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Document Has Been Signed on 11/04/2021 02:05 PM - It Cannot Be Edited


Created By: Albert Marin On 11/04/2021 at 10:56 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
80072(a)(2)

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80072 Personal Rights...each client shall have personal rights which include, but are not limited to...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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AD will caulked the lining of the shower wall. Immediate threat reduced. AD will submit plan for its renovation to CCLD on or before November 18, 2021.
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Based on observation, the facility failed to provide safe and healthful furnishings and equipment to client's needs. As verified with AD, in client room, switch cover was broken; and the common bathroom shower wall was in disrepair and with black discoloration. This poses immediate threat on the health and safety of clients in care.
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LPA provided a copy of the regulation section 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


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