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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005599
Report Date: 11/21/2022
Date Signed: 11/21/2022 01:29:54 PM

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
11/15/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20221115083100
FACILITY NAME:A1 ELDER CAREFACILITY NUMBER:
306005599
ADMINISTRATOR:SHAH, BINDIFACILITY TYPE:
740
ADDRESS:2538 E LARKSTONE DRIVE #ATELEPHONE:
(949) 929-5318
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:6CENSUS: 5DATE:
11/21/2022
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Bindi ShahTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Licensee did not obtain a building permit prior to physically altering the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman along with Code Compliance Supervisor Rafael Perez, and Code Compliance Officers Ines Guzman, Antonio Olivos, and Adam Davis conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA and Code Compliance were greeted and granted entry into the facility by Administrator Bindi Shah and explained the reason for the visit. Licensee Jitendra Shah arrived during the visit.
During the visit, LPA and Code Compliance toured the facility with Administrator Bindi as well as interviewed staff and resident. Regarding the allegation that Licensee did not obtain a building permit prior to physically altering the facility, the investigation revealed the following: Administrator and Licensee state a wall was put up to split a resident room into two private rooms and a permit was not pulled. LPA reviewed facility floor plan which shows the floor plan does not match the actual physical plant.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 and a copy of this report was provided to facility administrator along with appeal rights
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
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 2
Control Number 22-AS-20221115083100
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: A1 ELDER CARE
FACILITY NUMBER: 306005599
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2022
Section Cited
CCR
87305(a)
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Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not being met as evidenced by:
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Licensee to obtain a building permit and forward proof to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure a building permit was obtained before making changes to the facility. This poses an immediate health and safety risk to residents in care.
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Type B
CCR
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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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2