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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 12/07/2021
Date Signed: 12/07/2021 01:39:22 PM

Document Has Been Signed on 12/07/2021 01:39 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:
12/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Administrator Abdol Arastoo TIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPA) Albert Marin made an unannounced Case Management visit to do health and safety checks, and plan of corrections for the violations cited during previous visits. LPA spoke with Administrator (AD) Abdol Arastoo and stated the purpose of the visit. AD arrived in the facility about 11:55 AM.
LPA Marin conducted a tour of the facility, which included but not limited to random client’s rooms, common bathrooms, common areas, dining hall, kitchen and medication room. The facility met the minimum 2 day perishable and 7 day non-perishable food stock requirements. Cleaning and hygiene supplies were also observed and in place. LPA observed 23 clients in the facility and one staff member on the floor. LPA observed the meal service of the facility. LPA reviewed facility files which included but not limited to admission agreement, physician’s reports, and needs and services plans.

On deficiency and citation issued on November 4, 2021 on observation that one of the common bathrooms in Building A was in disrepair, AD Arastoo will provide written plan of work before the end of business day today.
LPA Marin revisited and discussed with AD Arastoo the staffing resource information. LPA provided with list of home care organizations as a resource for this facility. AD acknowledged its receipt. LPA reminded AD the discussion that transpired during the Non-Compliance Conference (NCC) held last November 16, 2021. LPA highlighted the need to prioritize the staffing complement of the facility. As discussed in the meeting, the facility needs to hire additional care staff, security, and cooks. LPA provided with AD with copies of the NCC. LPA also discussed with AD the California Code of Regulation (CCR) Section 85065 Personnel Requirements. LPA informed AD that the facility can not admit new clients until facility has hired additional staff. AD acknowledged the direction.

Due to time constraints, this visit will be completed at a later time.

No citation has been issued on this visit.

LPA Marin conducted an exit interview with AD Arastoo; and copies of this report, CCR 85065, NCC and list of Confidential Names were left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2021
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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