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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 12/13/2021
Date Signed: 12/13/2021 11:21:17 AM

Document Has Been Signed on 12/13/2021 11:21 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: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:
12/13/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Albert Marin conducted an unannounced case management visit and health and safety check. Via phone, LPA spoke with Administrator (AD) Abdol Arastoo; and informed AD the purpose of this visit.

AD Arastoo gave updates taken by the facility to comply with the staffing requirement discussed Non-Compliance Conference meeting held last November 16, 2021. Per AD Arastoo, he utilized the staffing registry and arranged for a staff to report to this facility. AD agreed to provide Community Care Licensing Division (CCLD) Orange Regional Office with copies of the contract with a staffing agency. AD also discussed updates on the deficiencies observed during the last visit.

LPA counted a tour of the interior and exterior portions of the facility. LPA inspected random client's rooms, common bathrooms, hallways and common area, and kitchen. LPA observed the lunch meal service which startedf about 11:00 AM. Clients lined up as the meal was served. Lunch served was consistent with the posted menu comprised of carbohydrates, proteins, and vegetables and fruits. LPA observed about 21 clients in the dining area and one staff member on the floor. LPA did not observe immediate threat on the health and safety of clients in care.

No citation was issued during this visit.

LPA Marin conducted a phone exit interview with AD Arastoo. AD gave permission for staff to sign and receive the report. LPA left a copy of this report in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2021
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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