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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 12/22/2021
Date Signed: 12/22/2021 02:50:28 PM

Document Has Been Signed on 12/22/2021 02:50 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: 24DATE:
12/22/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Abdul Arastoo, AdministratorTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to conduct case management in this facility. LPA arrived at facility was greeted and granted entry by caregiver. Administrator arrived shortly after and met with LPA. LPA explained 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 8-11 clients in the common areas. LPA toured the kitchen; it was observed that kitchen has a 2 day supply of perishables and 7 day non-perishable food available. LPA observed the kitchen work areas were clean. LPA observed Staff 1 was in the kitchen preparing dinner which is consistent with posted menu; and Staff 2 was checking the clients in care/cleaning. 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. Per random interviews with clients, meal served was consistent with the menu. Clients expressed enjoyment of the Christmas lunch party that was held on today's date for clients. LPA did not observe immediate threat on the safety of the clients in care.

LPA reviewed and obtained a copy the LIC500 Personnel Summary. AD confirmed that the LIC500 Personnel Report of today is current and up to date. AD verified that they have an open contract with staffing agency and has requested staffing from Monday to Sunday.

For this visit, no citation was issued.

LPA Martinez conducted an exit interview with Administrator and copy of this report was left in the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2021
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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