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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 05/24/2022
Date Signed: 05/24/2022 10:35:32 AM

Document Has Been Signed on 05/24/2022 10:35 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: 24DATE:
05/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:22 AM
MET WITH:Administrator (AD) Abdol ArastooTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility to conduct a case management for an incident. LPA met with Administrator (AD) Abdol Arastoo; and stated the purpose of this visit.

On May 23, 2022, Community Care Licensing Division (CCLD) Orange Office received an incident report from the facility describing an incident report that occurred last May 10, 2022 that involved Client 1 and Client 2.

For this visit, LPA Marin toured the interior and exterior portions of the facility. LPA observed about 10 clients out in common area, one staff member, and AD Arastoo on the floor. LPA conducted medication and file review, and interviews.

Per AD Arastoo, after receiving the incident, he followed up with Client 2's care coordinator regarding the untoward behavior; and spoke with the two clients.. On May 20,2022, AD received a copy of the behavior contract from care coordinator for Client 2. No further similar incident occurred between two clients in care.

For this visit, no citation was issued.

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: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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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