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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004530
Report Date: 12/01/2021
Date Signed: 12/02/2021 03:10:39 PM

Document Has Been Signed on 12/02/2021 03:10 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:ABDOL ARASTOOFACILITY TYPE:
735
ADDRESS:8592 LAMPSON AVENUETELEPHONE:
(714) 534-4457
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 26CENSUS: 25DATE:
12/01/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:04 PM
MET WITH:Administrator Abdul Arastoo TIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to conduct a case management in this facility. LPA Marin was granted entry in the property. Administrator (AD) Abdul Arastoo was informed about the presence of LPA in the facility. AD arrived in the facility shortly after. LPA informed AD the purpose of this visit

LPA Marin conducted a tour in the interior and exterior portions of the facility. LPA inspected random clients rooms; and common areas. LPA tested the battery operated smoke and carbon monoxide detectors and were observed to be operational. LPA observed about 10 clients in common areas and one staff member on the floor. AD gave update on staffing plan of the facility. AD agreed to provide LPA with updated copy of LIC 500 (Personnel Summary Report) and employment documents of the prospective staff by the end of business day today.

For this visit, no citation has been issued.

LPA Marin conducted an exit interview with AD Arastoo. LPA left a copy of this report and list of home care organizations for use and reference of the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2021
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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