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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 11/02/2021
Date Signed: 11/02/2021 12:54:43 PM

Document Has Been Signed on 11/02/2021 12:54 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:ABDUL ARASTOOFACILITY TYPE:
735
ADDRESS:8592 LAMPSONTELEPHONE:
(714) 534-4457
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 26CENSUS: 25DATE:
11/02/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:27 AM
MET WITH:Administrator Abdul ArastooTIME COMPLETED:
01:10 PM
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Licensing Program Analysts (LPAs) Albert Marin, Ruth Martinez, and Jerome Haley made an unannounced visit to this facility to conduct a case management. Staff 1 called and informed Administrator (AD) Abdul Arastoo about the presence of LPAs in the facility. AD Arastoo arrived in the facility about 11:43 AM. LPA Marin spoke to AD Arastoo and stated the purpose of the visit.

LPAs Marin, Martinez and Haley conducted a tour of the interior and exterior portions of the facility, which included but not limited random client's rooms, common bathrooms, kitchen, dining area and outside common areas.

LPAs discussed with AD the procedure of the facility when receiving reports concerning the health and safety of clients in care. LPA Marin also discussed with AD the best practices in facility documentation.

Due to time constraints, this visit will be completed at a later time.

No citation has been issued at this time.

LPA Marin conducted an exit interview with AD Arastoo and copy of this report was left in the facility. AD agreed to provide documentation on the latest inspection completed for the fire alarm of the facility.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2021
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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