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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 11/08/2021
Date Signed: 11/08/2021 04:24:25 PM

Document Has Been Signed on 11/08/2021 04:24 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: 22DATE:
11/08/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:59 PM
MET WITH:Abdul ArastooTIME COMPLETED:
04:41 PM
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Licensing Program Analysts (LPAs) Joseph Alejandre and Jerome Haley made an unannounced visit to conduct a health and safety inspection of the facility. LPAs met with Administrator Abdul Arastoo and explained the reason for the visit. LPAs and Administrator toured the facility. The facility is composed of two buildings each building houses clients, the main building has the kitchen and dining room which also acts as the main room for watching TV. LPAs observed the facility has a 2 day perishable and 7 day non-perishable food supply on hand. Dinner had started being served when the LPAs arrived. Dinner was rice with chicken curry with vegetables and chocolate pudding for desert and ice tea or water to drink. LPAs observed that the carbon monoxide detectors were operational. LPAs observed all of the lights were working along with the gas stove which can light unassisted. LPAs observed the facility does have utility service; hot water and electricity and gas. LPAs observed on the side of the main building there is hole in the ground where the plumbing was fixed. LPAs observed the medication room is locked and inaccessible to clients. No deficiencies are being cited as a result of this visit. An exit was conducted and copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2021
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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