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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 01/03/2022
Date Signed: 01/03/2022 04:02:47 PM

Document Has Been Signed on 01/03/2022 04:02 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:
01/03/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:26 PM
MET WITH:Administrator Abdul Arastoo TIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to conduct a case management and health and safety check in this facility. Via phone, LPA spoke to Administrator (AD) Abdul Arastoo and stated the purpose of this visit. AD arrived in the facility about 20 minutes after.

LPA Marin conducted a tour in the two buildings. LPA observed about 12 clients in common areas; and 2 staff members on the floor. LPA toured random client's rooms; and common areas. LPA reviewed the Coronavirus 2019 (COVID 19) mitigation plan of the facility. LPA observed staff completing daily temperature checks for the clients. LPA discussed with AD continue using disposable utensils as part of the infection control plan of the facility. AD stated that on Thursday, December 30, 2021, The Orange County of Public Health conducted mass testing for 23 clients in care. AD will follow up the testing results with the agency.

LPA also discussed best practices in documenting clients going out and coming back of the facility. AD will hold another round of meeting with clients to reinforce house rules; and to will also do staff training on endorsements.

LPA Marin reviewed the deficiencies observed during the previous visits. AD discussed that the maintenance person will be in the facility to do physical plant repairs and do remodelling of common bathroom in Building A. LPA observed on going remodelling of common bathroom in Building A; and bathroom door being replaced in Building B. LPA also observed repair was done in kitchen and hallway door in Building B.

AD Arastoo provided LPA with latest copy of personnel summary report.

For this visit, LPA Marin did not observed immediate threat on the health and safety of clients in care.

LPA Marin conducted an exit interview with AD Arastoo. Copy of this report was left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2022
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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