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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 02/04/2022
Date Signed: 02/04/2022 12:30:50 PM

Document Has Been Signed on 02/04/2022 12:30 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: 23DATE:
02/04/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:36 AM
MET WITH:Administrator Abdul Arastoo TIME COMPLETED:
01:00 PM
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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. LPA met with Administrator (AD) Abdul Arastoo and stated the purpose of the visit.

LPA toured the interior and exterior portions of the facility with AD Arastoo.. LPA observed 22 clients in care and two staff members on the floor. In Building A, LPA tested the smoke and carbon monoxide detector to be in good repair. Fire control panel was inspected last November 2021. Remodelling of Bathroom 1 was observed to be almost done and waiting for sink soap dispenser and shower curtain to be installed. Common bathroom 2 was in good repair and programmed to be repainted. 2 out of 5 clients rooms had been repainted including the hallway, and common areas. Per AD, the repair and replacement of the closet door in Room 2A was on the repair list. LPA observed the materials for replacement available in the facility. Facility replaced the light system in the dining area and in the kitchen. On the bulletin board, LPA observed a posted activity program for February 2022. Kitchen appeared clean and pest free. Facility met the minimum 2 day perishable and 7 day non-perishable food stock requirements. Medication room was observed to be locked at all times. LPA randomly reviewed morning medications and did not observed any discrepancy. LPA observed the lunch meal service. Food served was consistent with the posted menu which consisted of protein, carbohydrate and a piece of fruit.

In Building B, LPA observed a maintenance person working on remodelling Bathroom 1. LPA tested the carbon monoxide and smoke detector to be in good repair. Window blinds in room 4B was broken and was replaced on site. Hallway walls had been repainted. Room 3B underwent during the visit. Supply room was observed to be locked and inaccessible to clients in care. Laundry units were observed to be operational. Non- functional vending machines were still inside the building waiting to be picked up.

LPA requested copy of updated personnel summary report.

For this visit, LPA did not observed immediate threat on the health and safety of clients in care. No citation has been issued at this time.

LPA Marin conducted an exit interview with AD Arastoo and copy of this report was left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2022
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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