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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 05/10/2022
Date Signed: 05/10/2022 03:55:25 PM

Document Has Been Signed on 05/10/2022 03:55 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: 23DATE:
05/10/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Marjan Arastoo, Abdol ArastooTIME COMPLETED:
03:10 PM
NARRATIVE
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On 05/10/2022, a virtual meeting was conducted by the Department to discuss the finances of Prime Care Manor. Present at the meeting was Licensee, Prime Care Manor, Inc. represented by Marjan Arastoo and Abdol Arastoo. Representing the Department were Regional Manager (RM) Marina Stanic, Licensing Program Managers (LPMs) Luz Adams, Sheila Santos, and Armando Lucero, and Licensing Program Analysts (LPAs) Albert Marin, Edward Tapia, Lydia Martinez, Joseph Alejandre, and Sean Haddad. Also present were General Auditor Jessica Chen and Audit Manager Jacqueline Juarez from the Community Care Licensing Audit Section and Mark Shugarman from the Orange County Health Care Agency.

Jessica Chen, General Auditor III, reviewed the Solvency Audit Report dated 04/08/2022. Based on the Solvency Audit Report, the Department determined that the Licensee is not experiencing financial difficulties. The bills are paid on time, and sufficient cash reserves are maintained in their bank accounts. The risk the Licensee becomes insolvent, is low. The facility’s non-compliance in regard to repair, lack of staff and nutritious food, and other issues was therefore due to management lack of oversight.

Based on the Solvency Audit Report, the Licensee did not exercise general supervision of the licensed facility’s operation as required by CCR, Title 22, Division 6, Chapter 1, Section 80063 Accountability. The following deficiency is being cited: (See LIC 809D).

An exit interview was conducted with the Licensee and a copy of this report LIC809, LIC809D, the Solvency Audit Report dated 04/08/2022, and a copy of appeal rights was provided to the Licensee.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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 05/10/2022 03:55 PM - It Cannot Be Edited


Created By: Sean Haddad On 05/10/2022 at 03:26 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: 05/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2022
Section Cited
CCR
80063(a)

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80063 Accountability (a) The licensee, …, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation. This requirement was not met as evidenced by: Based on the Solvency Audit Report dated 04/08/2022, the Licensee
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The Licensee agreed to provide to LPA a plan for compliance addressing maintenance, budget for activities and staffing, etc., by 5/20/22.
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did not oversee the facility to ensure compliance as evidenced by the facility’s non-compliance in regard to repair, lack of staff and nutritious food, and other issues, which poses an immediate health, safety, and personal rights risk to persons 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:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022


LIC809 (FAS) - (06/04)
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