<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 03/10/2022
Date Signed: 03/10/2022 11:52:46 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/10/2022 11:52 AM - 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:
03/10/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Adbul ArastooTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Albert Marin and Ruth Martinez made an unannounced visit to conduct case management - annual continuation. LPAs met with Administrator (AD) Abdul Arastoo and stated the purpose of this visit.

During the February 25, 2022 facility annual inspection visit, LPAs Marin and Martinez toured the interior and exterior portions of the facility with AD Arastoo. LPAs inspected each clients room; and observed that smoke sensor flashed a green light indicator. Fire alarm panel inspection was done last November 4, 2021. Carbon monoxide detector in each building were tested to be operational. Common bathrooms were provided with grab bars, and stocked with hygiene products. Hot water was measured from 110 to 115 degrees Fahrenheit. in the common dining area, LPAs observed posted menu for week, and weekly activities. Facility met the minimum 2 day perishable and 7 day no perishable food stock requirements. Kitchen sharp items were kept inside the kitchen not accessed by clients in care. Cleaning supplies and toxins were stored in a locked supply room located in Building B. Medications were kept in a cabinet inside the medication room and rendered inaccessible to clients. Grounds were provided with chairs and free of any obstruction hazards.

During February 25, 2022 visit, the following deficiencies were observed and verified with AD Abdul Arastoo:
  • 10:00 AM, in Room 2A: Clutter inside the room. Personal belongings of Client 1 were observed on the floor. Bed of Client 1 did not have the necessary linen. Mattress of Client 1 was covered with stains.
  • 10:02 AM Room 1A: Electric fan grill and blade were coated with black material consistent with dust.
  • 10:07 AM Common Bathroom 2 in building A: Stains around the sink and below the soap dispenser consistent of liquid or water damage. Exhaust vents were found with cobwebs, and covered with black material consistent with grease and dust.
  • 10:10 AM Kitchen: Cupboard surfaces were covered with brown to black grainy surfaces. Stove exhaust were covered with brown to black material consistent with grease and dust. Floor under the movable rack appeared to be partly covered by black and greasy material. Under sink cabinet was in disrepair with broken cabinet wall and floor.
  • 10:13 AM Kitchen: Inside the refrigerator, 2 servings of ice cream were observed with no cover; and unopened cauliflower packaging with brown to black inside growth consistent with molds.
  • 10:41 AM, LPA Marin reviewed the sign out and sign in log and observed that Client 2 was not in the facility and did not sign out.
(Continuation in Page 2)
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
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: 03/10/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
For this visit, LPAs Marin and Martinez discussed the above deficiencies with AD Arastoo, and issued citations and assessed civil penalties per Title 22 Division 6 of the California Code of Regulations. LPAs discussed the appeal rights with AD. LPAs also discussed the advisory notes generated from February 25, 2022 visit.

LPAs Marin and Martinez conducted an exit interview with AD Arastoo. Copies of this report, LIC809 D (deficiency Page), LIC 421 Civil Penalty Assessment Form, appeal rights, advisory notes, and of CCR sections cited were left in the facility.

(Page 2)
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/10/2022 11:52 AM - It Cannot Be Edited


Created By: Albert Marin On 03/10/2022 at 07:42 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: 03/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/25/2022
Section Cited
CCR
80076(a)(1)

1
2
3
4
5
6
7
80076 Food Services. ...(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients....All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
On 2/25/22 visit, AD discarded the cauliflower. Immediate threat reduced. As plan of correction the facility will assign a person to do a weekly check of the supply and ensure that they are in good quality. Facility will provide proof of written instruction to the staff and copy of the inspection. AD will provide proof of correction by March 25, 2022
8
9
10
11
12
13
14
Based on observation, the facility did not store all foods in a safe and healthful manner. LPA observed an unopened package of cauliflower with possible mold formation Inside the refrigerator. Cupboard surfaces were stained. Stove exhaust was lined with dust and grease. This posed immediate threat on the health and safety of clients in care.
8
9
10
11
12
13
14
Copy of CCR Section 80076 was provided to AD for full reference.
Type A
03/25/2022
Section Cited
CCR80076(a)(14)

1
2
3
4
5
6
7
80076 Food Services... (14) All foods or beverages capable of supporting rapid and progressive growth of microorganisms which can cause food infections or food intoxications shall be stored in covered containers at 45 degrees F (7.2 degrees C) or less. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
On 2/25/22 visit, AD discarded the uncovered food items. Immediate threat reduced. As plan of correction, facility will ensure all food items kept in the refrigerator and freezer are covered. Facility will create a daily temperature log for refrigerator and freezer. Facility will create cleaning schedule for freezer an refrigerator and log completed task.
8
9
10
11
12
13
14
Based on observation, the facility did not store all foods in covered containers. Inside the refrigerator, LPA observed two servings of ice cream with no cover. This posed immediate threat on the health and safety of clients in care.
8
9
10
11
12
13
14
Proof of correction will be submitted to CCLD on or before 03/25/22.

Copy of CCR Section 80076 was provided 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: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/10/2022 11:52 AM - It Cannot Be Edited


Created By: Albert Marin On 03/10/2022 at 08:01 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: 03/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/25/2022
Section Cited
CCR
80072(a)(2)

1
2
3
4
5
6
7
80072 Personal Rights. (a) Each client shall have personal rights including: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
On 2/25/22 visit, AD directed staff to remove and clean up Room 2A. Immediate threat reduced. As plan of correction, AD will review the needs and services plan of the client and address issues on hand. AD will document that cleanliness of the room is monitored. Proof of correction will be submitted by 3/25/2022.
8
9
10
11
12
13
14
Based on observation and interviews , Facility did not accord safe, healthful and comfortable accommodations to each client. Client 1’s personal belongings were scattered all over the floor of the room shared with another client. This posed immediate threat on the personal rights of the client in care.
8
9
10
11
12
13
14

Civil penalty assessed for repeat violation.

LPA provided AD with copy of the regulation cited for full reference.
Type B
03/25/2022
Section Cited
CCR80087(a)

1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
 As plan of correction, facility will schedule create schedule for deep cleaning of all common bathrooms and log. And maintain sanitary environment at all times. AD will do deep cleaning of the bathrooms. Proof of correction will be provided to CCLD on or before 3/25/2022.
8
9
10
11
12
13
14
Based on observation and interviews, facility failed to keep clean, safe, sanitary and in good repair at all times. LPA observed common bathroom in Building A was stained and appeared unsanitary; kitchen floor covered with grease and dust. broken kitchen under sink cabinet. This posed possible threat on health and safety of clients in care.
8
9
10
11
12
13
14
Civil penalty assessed for repeat violation

LPA provided AD with copy of the regulation cited 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: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 03/10/2022 11:52 AM - It Cannot Be Edited


Created By: Albert Marin On 03/10/2022 at 08:19 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: 03/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2022
Section Cited
CCR
85088(c)(4)(A)

1
2
3
4
5
6
7
85088 Fixtures, Furniture, Equipment, and Supplies. ...Clean linen in good repair, including lightweight, warm blankets and bedspreads; ...quantity of linen provided shall permit changing the linen at least once each week ... to ensure that clean linen is in use by clients at all times. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
As plan of correction, Facility will provide clean linens in good repair and in amount sufficient to cover the bed and allow change at least a week or as necessary. AD will provide additional sheets for use of clients. Proof of correction will be provided to CCLD on or before 3/25/2022.
8
9
10
11
12
13
14
Based on observation and interview, Facility did not provide clean linen in good repair and enough quantity of linens to permit changing at least once a week. Client 1 did not have necessary clean linen to cover the mattress and box spring; and no extra linen to permit change at least once a week. This posed potential risk on the health and safety of clients in care.
8
9
10
11
12
13
14
LPA provided AD with copy of the cited regulation for full reference.
Type B
03/25/2022
Section Cited
CCR85088(c)(1)

1
2
3
4
5
6
7
85088 Fixtures, Furniture, Equipment, and Supplies. ...(1) An individual bed,...maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s).This requirement is not met as evidenced by:
1
2
3
4
5
6
7
As plan of correction, facility will ensure that all the beds are maintained clean and in good repair. AD will replace the mattress of Client 1. Proof of correction will be provided to CCLD on or before 3/25/2022.
8
9
10
11
12
13
14
Based on observation, facility did not maintain bed with clean mattress and pillows. As verified with AD, Client 1's mattress appeared with multiple stains. This posed potential threat on the health and safety of clients in care.
8
9
10
11
12
13
14
LPA provided AD with 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: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022


LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 03/10/2022 11:52 AM - It Cannot Be Edited


Created By: Albert Marin On 03/10/2022 at 08:39 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: 03/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/25/2022
Section Cited
CCR
80065(a)

1
2
3
4
5
6
7
80065 Personnel Requirements. (a) 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 is not met as evidenced by:
1
2
3
4
5
6
7
AD immediately reminded staff to ensure all clients are accounted for at all times. Immediate threat reduced. As plan of correction AD will give training to staff and documents of meeting with clients reviewing the house rules specifically in going out and coming back of the facility. Proof of correction will be provided to CCLD on or before 03/25/2022.
8
9
10
11
12
13
14
Based on interviews, interviews, file review and as verified with AD, facility did not provide services necessary to meet the clients needs at all times. Client 2 was not observed to be in the facility; and upon review of log, client did not sign out. This posed immediate threat on the safety of clients in care.

8
9
10
11
12
13
14

Civil penalty was assessed.

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

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022


LIC809 (FAS) - (06/04)
Page: 5 of 6