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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 12/10/2021
Date Signed: 12/10/2021 05:22:42 PM

Document Has Been Signed on 12/10/2021 05:22 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:ABDOL ARASTOOFACILITY TYPE:
735
ADDRESS:8592 LAMPSON AVENUETELEPHONE:
(714) 534-4457
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 26CENSUS: 25DATE:
12/10/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Abdol ArastooTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to continue the case management initiated last December 7, 2021 in this facility. Administrator (AD) Abdol Arastoo arrived in the facility shortly after receiving information about the presence of LPA in the facility. LPA stated the purpose of the visit.

On December 9, 2021, Regional Manager (RM) Marina Stanic conducted a video teleconference meeting with Licensee Marjan Arastoo and AD A. Arastoo. Licensing Program Manager (LPM) Luz Adams, and LPAs Albert Marin and Lydia Martinez were also present. RM Stanic reiterated required corrections (including the additional staffing) that need to be met by due date of December 15, 2021 as discussed during the non-Compliance Conference (NCC) meeting held last November 16,2021. Licensee was encouraged to work closely and collaboratively with Community Care Licensing (CCL) staff. LPAs Marin and Martinez provided Licensee and Administrator with list of the staffing registry.

LPA Marin conducted a tour of the facility which included client rooms, common bathrooms, dining hall, kitchen and facility grounds. LPA observed 1 staff member on the floor and 20 clients on the floor . LPA reviewed the sign in and out log and observed five clients were out of the facility. LPA reviewed the Coronavirus 2019 (COVID 19) mitigation plan. LPA observed staff member wearing mask while at work. COVID 19 booster shots had been given on December 1, 2021 to most clients in care. LPA observed that the soda and vending machines were empty and not in service during the visit. Lunch meal service was completed when LPA arrived in the facility; but based on the interview, meals served were consistent with the posted menu. The serving consisted of protein, greens, and choice of fruit (orange or apple).

LPA Marin conducted consultation with Staff 1 about having a specific log for endorsements for the Administrator. Staff 1 provided a notebook and labelled it as staff book endorsement book. LPA discussed with AD best practices with in facility documentation and to utilize maintenance logs for the facility physical plant, observation logs for the clients, and staff endorsement logs.

(Continuation on page 2)
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2021
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: 12/10/2021
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(Continuation from Page 1)

LPA Marin described the following deficiencies and verified with AD Arastoo:
  • Facility has only one day shift staff was on the floor to supervise 20-25 clients in care. The staff is working in the kitchen preparing meals, attending to phone calls, attending to clients’ needs and concerns, medication management, and housekeeping in one shift. Per file review of latest personnel report signed on December 07, 2021, LPA observed one staff member covers for evening shift (3:00 PM to 11:00 PM) and one for night shift (11:00 PM to 7:00 AM).

  • On this visit, LPA observed that two out of five clients rooms inspected were in disarray and room furniture were in disrepair. A bed in Room 5A was in disrepair.

  • During the file review conducted in December 7, 2021, LPA observed that the needs and services plan on file for Client 2, Client 4, Client 6, Client 10, Client 12, Client 14, Client 16, Client 17, and client 19 were signed and completed more than a year ago.

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 A. Arastoo. LPA explained the deficiencies, citations, and appeal rights. Due to technical issues encountered during the visit, AD agreed to receive copies of this report, confidential names, deficiency pages, and appeal rights via email.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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Document Has Been Signed on 12/10/2021 05:22 PM - It Cannot Be Edited


Created By: Albert Marin On 12/10/2021 at 11:13 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: 12/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2021
Section Cited
CCR
80065(a)

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80065 Personnel Requirements. Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement was not met as evidenced by:
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AD posted position vacancies. Threat reduced. AD will provide and employ adequate staff members identified in NCC by 12/15/21. AD will ensure that facility has adequate staff to meet the needs of the clients in care. AD will submit proof of correction to CCLD on or before 12/15/2021.
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Based on observation, interview and file review, facility do not have personnel to meet individual clients need at all times. As verified with AD , there is only one staff on the floor for two buildings. Staff works as cook, medication technician and care staff, housekeeping in one shift. This poses immediate threat on health and safety clients in care.
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LPA provided a copy of the cited regulations to AD for full reference.
Type A
12/15/2021
Section Cited
CCR80087(a)

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80087 Buildings and Grounds. The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by:
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AD will repair or replace the bed furniture. Threat reduced. AD will ensure that the facility is clean, safe, sanitary and in good repair at all times. Proof of correction will be submitted to CCLD on or before 12/24/2021.
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Based on observation and interviews, facility failed to keep clean, safe, sanitary and in good reapir at all times. As verified with AD, the bed furniture a client in Room 5A was in disrepair. This poses immediate threat on the health and safety of client in care.
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LPA provided copy of the cited regulation 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: 12/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2021


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Document Has Been Signed on 12/10/2021 05:22 PM - It Cannot Be Edited


Created By: Albert Marin On 12/10/2021 at 11:26 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: 12/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/31/2021
Section Cited
CCR
80068.3(a)

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80068.3 Modifications to Needs and Services Plan. The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file. This requirement was not met as evidenced by:
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AD will update the needs and services plan of nine
clients as identified in the confidential names list. Ad will ensure to that all needs and services plan of all clients are updated and current at all times and are on file. AD will submit proof of correction to CCLD on or before 12/24/2021.
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Based on file review, licensee failed to ensure that client's written Needs and Services plan is at least updated annually or as often as necessary. As verified with AD, there were 9 clients who did not have updated needs and services plan on file. This poses potential health and safety concerns to clients in care.
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LPA provided AD will copy of the cited regulations 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: 12/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2021


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