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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004530
Report Date: 11/09/2023
Date Signed: 11/09/2023 11:37:32 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/05/2023 and conducted by Evaluator Kimberly Lyman
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230705155329
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:
11/09/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Virginia Martin and Abdol ArastooTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility issued client an unlawful eviction
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced complaint visit to deliver findings on the above allegation. LPAs were greeted and granted entry into the facility and explained the reason for the visit. Administrator Abdol Arastoo arrived during the visit.

During the course of the investigation, LPAs toured the facility, interviewed staff and client as well as reviewed and obtained pertinent documentation such as eviction notice. Regarding the allegation that facility issued client an unlawful eviction, the investigation revealed the following: Facility served Client 1 (C1) an eviction notice on 07/02/2023. The eviction notice did not include required documentation as well as no copy was provided to Client's responsible party rendering the eviction notice as unlawful. Based on record review, the preponderance of evidence standard has been met. Therefore the above allegation is found to be Substantiated. California Code of Regulations,(Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted with facility representative and a copy of this report was provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 22-AS-20230705155329
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2023
Section Cited
CCR
80068.5(D)
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When serving the client with either a 30-day or a 3-day notice to quit, the licensee shall, on the same day, overnight mail or fax a copy of the notice to the client's authorized representative, if any or responsible person if there is no authorized representative. This req is not being met as evidenced by:
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Licensee to provide a statement of understanding of the regulation to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure a copy was provided on the same day to responsible party. This poses a potential health and safety risk to residents 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/05/2023 and conducted by Evaluator Kimberly Lyman
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230705155329

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:
11/09/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Virginia Martin and Abdol ArastooTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility is not providing clients with clean bedsheets
Facility is not equipped with furniture in good repair
Facility has insects
Facility is not assisting with arranging medical appointments for client
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kimberly Lyman and Joseph Alejandre conducted an unannounced complaint visit to deliver findings on the above allegation. LPAs were greeted and granted entry into the facility and explained the reason for the visit. Administrator Abdol Arastoo arrived during the visit.

During the course of the investigation, LPAs toured the facility and interviewed staff and clients. Regarding the allegations that facility is not providing clients with clean bedsheets, facility is not equipped with furniture in good repair, facility has insects and facility is not assisting with arranging medical appointments for client, the investigation revealed the following: LPA observed Client 1's (C1) room. C1 's bedsheets appeared clean during the visit. LPA observed extra clean bedding on-site at facility. Four out of five clients indicated assistance with cleaning sheets and one out of four stated cleaning own sheets. LPA observed C1's dresser to be intact. C1 stated removing the client's bed frame for the client's preference. LPA observed furniture in facility is intact. LPA toured the facility on two different occasions and did not observe any evidence of insect infestation. Five out of five clients and two out of two staff CONT ON LIC 9099C DATED 11/09/2023
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20230705155329
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/09/2023
NARRATIVE
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deny any insect infestation. Facility administrator states taking C1 to a doctor's appointment but that client regularly declines appointments. C1 confirms declining doctor appointments. Based on observation and interviews conducted, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5