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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 12/15/2021
Date Signed: 12/15/2021 11:40:13 AM

Document Has Been Signed on 12/15/2021 11:40 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:
12/15/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Abdul ArastooTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to conduct case management in this facility. LPA met with Administrator Abdul Arastoo and stated the purpose of this visit.

LPA conducted a tour of the facility which included random client's rooms, common areas and kitchen. LPA observed two staff members on floor and 25 clients in care. LPA observed Staff 1 was in the kitchen preparing lunch which is consistent with posted menu; and Staff 2 was checking the clients in care. LPA also observed random clients cleaning respective rooms; ;laundry machine units were in good working order, and common bathrooms were stocked with liquid soap and paper towels. Vending and soda machines were observed not operational.

LPA Marin discussed California Code of Regulations (CCR) Sections 80065. LPA highlighted subsections (a), (b), (f)(1-6), (j), (k); and CCR Section 85065, subsections (d)(1), and (e)(2). Per CCR sections and Non- Compliance Conference held last November 16, 2021, this facility needs additional care staff for direct care and supervision of clients, full-time cook, activity person, housekeeping , laundry and security. LPA also discussed CCR Section 80068 Admission Agreements and highlighted the subsection (c)(1) Basic Services. LPA reviewed the current admission agreement of the facility and highlighted the conditions under basic general services which included laundry services, and housekeeping. LPA reviewed the staffing plan of the facility. AD discussed the that the contract with outside staffing agency is open. AD agreed to provide the written staffing plan to address the staffing needs as stated above; and an updated LIC500 personnel summary report.

LPA also discussed with AD on how to improve the documentation in the facility. AD agreed to document repairs completed ; and tasks that are pending. AD agreed to give reorientation to all clients regarding the general house rules; and document.

For this visit, no citation has been issued.

LPA Marin conducted an exit with AD Arastoo; and copies of this report and regulations discussed were left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2021
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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