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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 04/25/2022
Date Signed: 04/25/2022 12:55:23 PM

Document Has Been Signed on 04/25/2022 12:55 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: 25DATE:
04/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:46 AM
MET WITH:Administrator Abdul ArastooTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to continue the case management visit initiated last March 10, 2022. LPA met with Administrator (AD) Abdul Arastoo and stated the purpose of this visit.

Based on observation, file review and interview, about 9:00 AM of March 2, 2022, after facility check, staff members did not observed Client 1 (C1) in the facility. Staff reviewed sign out log and observed C1 did not complete a sign out entry before leaving the facility. Facility reported the C1 as a missing 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, C1 was discharged back to the facility. As a follow up, AD Arastoo brought C1 to primary care physician. Per physician's report dated March 24, 2022, C1 was determined to be able to leave the facility unassisted; and able to communicate. On April 19, 2022, Community Care Licensing Division (CCLD) Orange Office received a report stating that on April 11, 2022 about 9:00 AM staff members observed Client 1 leaving the facility but did not come back by 10:00 PM. The following morning facility reported C1 as a missing person. On April 13, 2022 about 5:30 PM, C1 came back to the facility. AD made a follow up with care coordinator to set up another medical appointment follow up.

For this visit, LPA conducted medication review; and interview Client 1 and facility staff. LPA conducted consultation on California Code of Regulations (CCR) Section 85075.4 Observation of the Client.; and best practices in facility documentation. AD discussed the absentee notification plan and course of action with client that comes back in the facility after the incident.

No citation was issued at this time.

LPA Marin conducted an exit interview with AD Arastoo; and copy of this report and CCR Section 85075.4 were left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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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