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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 02/25/2022
Date Signed: 03/08/2022 10:19:29 AM

Document Has Been Signed on 03/08/2022 10:19 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:
02/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator Abdul ArastooTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPAs) Albert Marin and Ruth Martinez made an unannounced required annual inspection in this facility. LPA met with Administrator (AD) Abdul Arastoo and stated the purpose of this visit.

The facility is composed of two building of single level structure and licensed for twenty six non- ambulatory.

About 9:20 AM, LPAs Marin and Martinez were granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. LPAs Marin and Martinez conducted a tour of the interior and exterior portions of the facility with AD A. Arastoo. the tour started with Building A which consists of five shared clients rooms, 2 and a half bathrooms, dining area, kitchen, and medication room. Building B consists of eight shared rooms, 3 full bathrooms and stock room for supplies. After the tour, LPAs conducted file review and review of medications, and interviews.

Due to time constraints, LPAs Marin and Martinez will complete this inspection in the next visit.

LPAs Marin and Martinez 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: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
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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