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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 03/02/2022
Date Signed: 03/02/2022 11:13:10 AM

Document Has Been Signed on 03/02/2022 11:13 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:
03/02/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced case management to continue the annual inspection initiated last February 25, 2022. Via phone, LPA spoke with Administrator (AD) Abdul Arastoo; and stated the purpose of the visit.

For this visit, LPA Marin conducted a tour of the interior and exterior portions of the facility, did a file review and interview.

No citation was issued on this visit.

Via phone, LPA Marin conducted an exit interview with AD Abdul Arastoo, AD gave permission for staff to receive and sign the report. LPA left copy of this report in the facility.


SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2022
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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