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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 12/27/2021
Date Signed: 12/27/2021 02:58:07 PM

Document Has Been Signed on 12/27/2021 02:58 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: 24DATE:
12/27/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Abdol ArastooTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Jerome Haley made an unannounced visit to conduct a case management in this facility. LPAs arrived at facility and were greeted and granted entry by Administrator Abdol Arastoo. LPAs explained the purpose of this visit.

LPAs conducted a tour of the facility which included random client's rooms, common areas and kitchen. LPA observed Administrator was on the floor and approximately eight clients in the common areas. LPAs toured the kitchen; it was observed that kitchen has a 2 day supply of perishables and 7 day non-perishable food available. LPAs observed the kitchen work areas were clean. LPA observed one staff was in the kitchen preparing dinner. Dinner was observed to be chicken pasta and vegetables. Vending and soda machines were observed but not operational. LPAs observed ample cleaning supplies as well as PPE. Facility has back-up supply of linens and towels. LPAs did not observe immediate threat on the safety of the clients in care. Facility does not have a covid sign in/ screening area in the facility. LPAs observed one restroom is under construction and administrator states working with a contractor to make improvements in the facility. LPAs toured select client rooms and observed the closet door in room A2 is in disrepair and has a hole in the door. Rooms 5A, A2, and 2 have walls that are soiled and have discoloration.

LPAs reviewed and obtained a copy the LIC500 Personnel Summary. AD confirmed that the LIC500 Personnel Report of today is current and up to date. AD verified that they have an open contract with staffing agency and has requested staffing from Monday to Sunday.
Facility was issued an advisory note during today's visit.

Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with Administrator


SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2021
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 12/27/2021 02:58 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 12/27/2021 at 02:27 PM
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: 12/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2022
Section Cited
CCR
80087(a)

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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 is not being met as evidenced by:
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Licensee to repair/ replace closet door and forward proof to LPA by POC due date.
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Based on observation, Licensee failed to ensure facility is clean, sanitary and in good repair. LPAs observed the closet door in room A2 is in disrepair and has a hole in it. This poses a potential health and safety risk to clients in care.
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2021


LIC809 (FAS) - (06/04)
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