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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004668
Report Date: 05/03/2024
Date Signed: 05/03/2024 03:01:19 PM

Document Has Been Signed on 05/03/2024 03:01 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:PRIMROSE RESIDENTAL CAREFACILITY NUMBER:
306004668
ADMINISTRATOR/
DIRECTOR:		LACY FADDOULFACILITY TYPE:
740
ADDRESS:651 PRIMROSE STREET S.TELEPHONE:
(949) 682-5229
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 1DATE:
05/03/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Valesca YahairaTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley arrived to complete the required one-year annual visit that was started May 1, 2024. LPA Haley was greeted and granted entry by staff and explained the reason for the visit. A phone call was placed to Licensee/Administrator Lacy Faddoul who could not attend with today's visit. LPA Haley and Administrator Faddoul briefly spoke on the phone regarding the citation that will be issued for Staff 1 (S1).

During the visit, LPA Haley completed the inspection tool, conducted interviews with staff and resident 1 (R1).

As a result of the annual inspection, deficiencies will be cited and a Technical Violation will be issued.

An exit interview was conducted, and a copy of this report and appeal rights were provided to staff.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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 05/03/2024 03:01 PM - It Cannot Be Edited


Created By: Jerome Haley On 05/03/2024 at 02:15 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: PRIMROSE RESIDENTAL CARE
FACILITY NUMBER: 306004668

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Water supplies and plumbing fixtures shall be maintained as follows:
(2) Faucets used by residents for personal care such as shaving and grooming... Hot water shall be maintained to automatically regulate... to attain a temperature of no less than 105 degree F (41 gedree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidenced by:
On May 1, 2024 during the inspection of the physical plan, the hot water was measured at 145.5 degree F in bathroom 1 and 134.4 degree F in bathroom #2. Photos were taken and S2 observed the hot water temperatures.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 resident bathrooms which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/04/2024
Plan of Correction
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Licensee Faddoul has adjusted the hot water temperature and will make sure the hot water temperature meets regulation requirements.
During the visit on May 3, 2024, the hot water temperature was measured at 105.4 degrees in bathroom and 100.00 degrees F in bathroom #2.
POC due date is May 4, 2024 at 1:00PM .
Type A
Section Cited
CCR
87355(e)(2)
(e) All individuals subject to a criminal record review... shall prior to working, residing or volunterring in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This requirement is not met as evidenced by:
Staff 1 (S1) was not associated to the facility roster during the May 1, 2024 annual inspection.
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 3 staff present in the facility during the annual inspection that started May 1, 2024 and completed May 3, 2024, which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/04/2024
Plan of Correction
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Administrator Faddoul associated S1 to the facility after the May 1, 2024 visit.
LPA Haley verified S1's association during the May 3, 2024 visit.
No further action needed.
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:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024


LIC809 (FAS) - (06/04)
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