<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 03/10/2025
Date Signed: 03/10/2025 05:12:55 PM

Document Has Been Signed on 03/10/2025 05:12 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PRIME CARE MANORFACILITY NUMBER:
306004530
ADMINISTRATOR/
DIRECTOR:		ABDOL ARASTOOFACILITY TYPE:
735
ADDRESS:8592 LAMPSON AVENUETELEPHONE:
(714) 534-4457
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 26CENSUS: 25DATE:
03/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPAs) Hanna Gough and Michael Tea arrived at the facility to conduct an unannounced Required 1-Year Inspection. LPAs were greeted and granted entry by staff. LPAs informed Administrator (AD) Abdol Arastoo the purpose of the inspection.

The facility is comprised of two buildings. Building A is a one-story building with five client bedrooms, three bathrooms, kitchen, medication room and a dining room. Building B is a one-story building with eight client rooms, three bathrooms and a laundry area.
All residents rooms had required components and furnishings. Facility had extra clean linens in a cabinet in building B. The facility has extra linens for clients in hallway cabinets. Restrooms are stocked with soap and paper towels. Hot water in Building A measured between 105.8-110.3 degrees Fahrenheit. The hot water in Building B bathrooms measured between 107.7-112.1 degrees Fahrenheit. LPAs observed the kitchen to be clean and free of debris. LPAs observed a 7 day non perishable and 2 day perishable supply of food. LPAs observed the emergency food and water supply located in the kitchen. The kitchen has a door that locks making sharps inaccessible to clients in care. LPAs observed all fire extinguishers in building A and building B to be fully charged with a service date of March 15, 2024. LPAs observed the centrally stored medication in a med room located in the dining room. LPAs observed toxins and chemicals are locked in a closet in building B and inaccessible to clients in care. The backyard has a shaded seating area for client use and is free of debris and obstructions. LPAs reviewed four of four client files and no discrepancies were observed. LIC 859 provided. LPAs reviewed two staff files and no discrepancies were observed. Staff trainings were not logged and accounted for during LPAs review of records, a type B citation was given on this date. LIC 858 provided. LPAs reviewed P&I log with AD and observed that the funds were not separated per regulations but was all accounted for. A technical violation was given on this date. LPAs reviewed four client medications and no discrepancies were observed.

Cont. on 809 C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 03/10/2025 05:12 PM - It Cannot Be Edited


Created By: Hanna Gough On 03/10/2025 at 04:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PRIME CARE MANOR
FACILITY NUMBER: 306004530

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 2 carbon monoxide detectors which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2025
Plan of Correction
1
2
3
4
Licensee will replace the carbon monoxide detector by the date above and send a video of the operational carbon monoxide detector to LPA by email or text.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Hanna Gough
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PRIME CARE MANOR
FACILITY NUMBER: 306004530
VISIT DATE: 03/10/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPAs observed the fire alarm and smoke detector in building A were operational. LPAs observed that fire alarm was operational in building B but the smoke detector was not. A type A citation was given on this date.

Based on the observations made during today's visit, two deficiencies and one technical violation is being cited as per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Abdul Arastoo and a copy of this report, deficiency pages, technical violation page and appeal rights were provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/10/2025 05:12 PM - It Cannot Be Edited


Created By: Hanna Gough On 03/10/2025 at 04:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PRIME CARE MANOR
FACILITY NUMBER: 306004530

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
80066(a)(6)
Personnel Records ... The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel records shall contain the following information: Documentation of ... training and/or experience specified in licensing regulations for the type of facility in which the employee works.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of 2 staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/01/2025
Plan of Correction
1
2
3
4
Licensee will train and document all staff and provide documentation to LPA via email by the date above.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Hanna Gough
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5