306004530-3-3-2026-22-AS-MTEA-DRU2A4-20260303161256

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 03/03/2026
Date Signed: 03/03/2026 04:13:03 PM

Document Has Been Signed on 03/03/2026 04:13 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 MANOR		FACILITY NUMBER:	306004530
ADMINISTRATOR/ DIRECTOR:	ABDOL ARASTOO		FACILITY TYPE:	735
ADDRESS:	8592 LAMPSON AVENUE		TELEPHONE:	(714) 534-4457
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY: 26		CENSUS: 25	DATE:	03/03/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:20 PM
MET WITH:	Abdol Arastoo		TIME VISIT/ INSPECTION COMPLETED:	04:28 PM

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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 26 non-ambulatory clients. Currently there are 25 clients during today's visit. The Administrator (AD) Abdol Arastoo arrived later to assist during the visit.

LPA Tea reviewed four client files and three staff files. Client files and staff files contained most of the required documentation. Upon review of records, the facility is up to date with the required quarterly emergency disaster drill, which was last conducted on January 5, 2026. The administrator’s certificate expires April 29, 2027.

LPA Tea along with AD Arastoo toured the physical plant. LPA toured the physical plant, checked food service, and the first aid kit. 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. In between the two buildings, there is shaded seating area for the clients to enjoy. Behind Building B there is a shaded patio area for residents to sit and relax as well. The kitchen was inspected. Only staff have access to the kitchen. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Emergency food and water supplies were in the kitchen. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. The fire and smoke detectors are serviced and maintained by a third-party company. Fire extinguishers throughout the facility are fully charged. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms

(Annual continuation on LIC809C)

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/03/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 03/03/2026

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were checked. Toilets and water faucets worked properly. Grab bars were secure, and showers were free of mold/mildew. The water temperature measured around 118.7 Fahrenheit degrees. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards; doorways were free of obstructions. First aid kit had all the required elements including bandages, dressing, tweezers, thermometer, and scissors. During the visit LPA Tea observed clients enjoying snacks, taking their medication and relaxing outside.

LPA reviewed medication storage and administration. Medications are stored in carts that are locked and secured in the medication room. Medications are being administered per physician order. P&I Funds were checked and there were no discrepancies. LPA interviewed clients regarding their quality of care.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Administrator Abdol Arastoo and copy of this report LIC809, 809-C, LIC858, LIC858-C, LIC859 were read and provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/03/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2026

LIC809 (FAS) - (06/04)

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