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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 06/27/2022
Date Signed: 06/27/2022 11:35:23 AM

Document Has Been Signed on 06/27/2022 11:35 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: 22DATE:
06/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Administrator (AD) Abdol ArastooTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced case management visit to this facility. LPA met with Administrator (AD) Abdol Arastoo and stated the purpose of this visit.

About 10:00 AM, LPA Marin conducted a tour of the interior and exterior portions of the facility. LPA observed 2 staff members and AD Arastoo on the floor, and about 8-10 clients in care in the common areas. Tour included but not limited to kitchen, medication room, and client’s rooms in Buildings A and B. AD discussed the role of the new staff member who oversees the activities of the clients in care. AD also stated that they will install the video surveillance system in this facility soon. AD stated that the dietician is finalized the facility the menu plan and will provide Community Care Licensing Division once it is completed.

LPA Marin reviewed the agreement described in the Non Compliance Conference completed last May 13, 2022.

No citation was issued on this visit.



LPA Marin conducted an exit interview with AD Arastoo. AD agreed to provide updated LIC 500 Personnel Summary Report by June 28, 2022. Copy of this report was left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2022
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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