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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 12/20/2021
Date Signed: 12/20/2021 01:16:31 PM

Document Has Been Signed on 12/20/2021 01:16 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:
12/20/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator Abdul Arastoo TIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Marin conducted an unannounced case management visit to this facility. LPA met with Administrator (AD) Abdul Arastoo and stated the purpose of this visit.

After granted entry in the facility, LPA observed two staff members on the floor and about 8-10 clients in the common area. LPA conducted a tour in the interior and exterior portions of the facility. LPA checked random client’s rooms and common areas. LPA observed that soda and snack vending machines were not operating. Per random interviews, meal served was consistent with the menu. During the visit, LPA also observed facility was serving snacks which consisted of granola bars and juice. LPA did not observe immediate threat on the safety of the clients in care.

LPA Marin discussed and reviewed the updates that the Administrator had done. Per discussion, on December 15, 2021 AD held a meeting with the clients in care. AD stated that he discussed the general house rules of the facility to include but not limited to sign in and sign out, mask requirements, and temperature checks. LPA discussed with AD best practices in communicating and maintaining the house rules of the facility. AD also consulted clients on activities that they wish to have including scheduling a holiday party in this facility.

LPA reviewed the LIC500 Personnel Summary with AD. AD confirmed that the LIC500 Personnel Report dated December 14, 2021 remains current. AD verified that they have an open contract with staffing agency and has requested staffing from Monday to Sunday.

LPA reviewed the deficiencies that were observed last December 10, 2021.

For this visit, no citation was issued.

LPA Marin conducted an exit interview with AD and copy of this report was left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2021
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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