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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006091
Report Date: 06/06/2022
Date Signed: 06/06/2022 10:32:08 AM

Document Has Been Signed on 06/06/2022 10:32 AM - 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:PRISTINE HOME CAREFACILITY NUMBER:
306006091
ADMINISTRATOR:ALVARADO, MARY JEANFACILITY TYPE:
740
ADDRESS:9252 PACIFIC AVETELEPHONE:
(714) 749-7237
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 4DATE:
06/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Mary Jean Alvarado and Clifford AlipingTIME COMPLETED:
10:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with complaint visit 22-AS-20220531115206. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Mary Jean Alvarado and Licensee Rod Alvarado arrived during the visit.

During the course of the complaint investigation, Administrator confirmed an incident reported by Resident 1's (R1) family on 05/26/2022. Administrator indicates terminating S1 after learning of abuse allegations. LPA did not receive verbal notification or an abuse report/ incident report from facility. LPA reviewed R1's file during the visit and observed the file has only an ID page and admission agreement and is missing all other components.








Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2022
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 06/06/2022 10:32 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 06/06/2022 at 10:04 AM
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: PRISTINE HOME CARE
FACILITY NUMBER: 306006091

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2022
Section Cited
CCR
87211(a)(D)

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Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: Any incident which threatens the welfare, safety or health of any resident.... This requirement is not being met as evidenced by:
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licensee to submit an incident report to CCL by POC due date.
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Based on interviews conducted, Licensee failed to ensure alleged abuse was reported to Community Care Licensing (CCL). This poses a potential health and safety risk to residents in care.
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Type B
06/13/2022
Section Cited
CCR87506(a)

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The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This req is not being met as evidenced by:
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Licensee to obtain all components for a complete file for R1 and forward proof to LPA by POC due date.
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Based on record review, Licensee failed to ensure R1 has a complete file on-site and available for review. 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.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022


LIC809 (FAS) - (06/04)
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