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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 09/28/2023
Date Signed: 09/28/2023 12:45:29 PM

Document Has Been Signed on 09/28/2023 12:45 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:
09/28/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Virginia Martin, Abdol ArastooTIME COMPLETED:
01:00 PM
NARRATIVE
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This unannounced Case Management – Health Checks inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of a health and safety check and to follow up on a self-reported incident report received in the Orange County Regional Office (OCRO) on 09/28/23 regarding Client #1 (C1). LPA met with Staff #1 (S1) Virginia Martin and explained the purpose of the inspection. Administrator (AD) Abdol Arastoo arrived during the inspection.

During the inspection, LPA and AD toured the facility. LPA observed there were 2 staff and 16 clients present. LPA conducted health and safety checks on the clients present and confirmed they were doing well and observed no health and safety issues. LPA observed the facility to be clean and organized and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed the electricity and water were running, the medications were properly stored, and the facility had soap and paper towels. LPA interviewed AD regarding C1, conducted additional interviews, and requested and reviewed copies of client roster, staff roster, relevant incident reports, and C1’s client file.

During the inspection, LPA and AD observed the following: based on review of billing records, the facility’s 2023 licensing fees have not been paid and have accrued late penalties.

Facility representative was advised that at this time further investigation is required. Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
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 09/28/2023 12:45 PM - It Cannot Be Edited


Created By: Sean Haddad On 09/28/2023 at 12:41 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: 09/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2023
Section Cited
CCR
80036(a)

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80036 Licensing Fees. (a) An applicant or a licensee shall be charged fees as specified in Health and safety Code Section 1523.1. This requirement was not met as evidenced by:
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Licensee stated they will pay the licensing fees immediately and submit proof to LPA by POC due date.
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Based on documents, the licensee did not ensure the facility’s 2023 annual fees were paid, which poses a potential 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: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023


LIC809 (FAS) - (06/04)
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