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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 03/10/2022
Date Signed: 03/10/2022 10:46:18 AM

Document Has Been Signed on 03/10/2022 10:46 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:
03/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Administrator Abdul ArastooTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPAs) Albert Marin and Ruth Martinez conducted a case management visit for an incident that occurred in this facility. LPAs met with Administrator (AD) Abdul Arastoo and stated the purpose of this visit.

On March 7, 2022, Community Care Licensing Division Orange Office received a report from the facility stating that on March 2, 2022, Client 1 was observed not to be in the facility. Facility reported the Client as a mission person to the local police department. On March 4, 2022, Facility received information that Client 1 was in the hospital for observation. On March 5, 2022, Client 1 was discharged back to the facility.

For this visit, LPAs Marin and Martinez conducted interview with AD Arastoo. LPAs discussed the list of documents requested from the facility. AD agreed to provide the documents by March 18, 2022.

No citation was issued during this 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: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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