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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191591729
Report Date: 07/17/2026
Date Signed: 07/17/2026 03:27:53 PM

Document Has Been Signed on 07/17/2026 03:27 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:C.M.A.FACILITY NUMBER:
191591729
ADMINISTRATOR/
DIRECTOR:		AMARSINGHE, SWARNAFACILITY TYPE:
735
ADDRESS:18432 GRIDLEY RD.TELEPHONE:
(562) 860-2479
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 48CENSUS: 46DATE:
07/17/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:02 AM
MET WITH:Manel "Swarna" Amarasinghe - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted required the annual inspection, LPA met Administrator Swarna Amarsinghe and explained reason for visit. The facility is licensed to serve 48 Ambulatory Only, Mentally Disabled Adults ages 18-59.

The facility is located in Artesia, CA and consists of 6 separate buildings.


Building 1 includes a living room, dining room, office, kitchen, six bedrooms (shared) and two bathrooms.Building 2 includes 2 bedrooms (shared) and 2 bathrooms. Building 3 includes 1 bedroom (shared), 1 bathroom, laundry room and pantry room. Building 4 includes 2 bedrooms and 1 bathroom. Building 5/Medication room includes 10 bedrooms (shared) and 5 bathrooms. Building 6/Trailer includes 3 bedrooms, 2 bathrooms, a living room/lounge, and a kitchen (without stove).

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:


Infection Control: Facility maintains the required Infection Control Plan.
Operational Requirements: The facility maintains the required fire clearance and plan of operation on file and as multiple outdoor shaded areas for the clients.
Staffing: There appears to be sufficient staffing at all times in the facility.
Personnel Records-Training: Administrator Manel "Swarna" Amarasinghe has a valid administrator certificate that expires on 3/24/28. During today’s visit LPA observed 6 staff files each were fingerprint cleared and had valid first-aid certificates, however, LPA observed the following deficiency: Health screening for S3 is blank with no physician signature and Health screening for S6 does not have staffs name which makes it difficult to confirm if health screening is for that particular staff, citation issued.
Client Rights-Information: Facility provides clients with telephone and internet. (Continued on LIC809C)
David Sicairos
Tena Herrera
DATE: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2026
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: C.M.A.
FACILITY NUMBER: 191591729
VISIT DATE: 07/17/2026
NARRATIVE
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Physical Plant & Environment Safety: Smoke detectors and carbon monoxide detectors are operable and in compliance. Bathrooms are clean and operational. 7 clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available to the residents. The fire extinguishers were observed and is fully charged. Facility has telephone service on premises. There is a sprinkler system approved by the fire marshal throughout the facility. The hot water temperature was tested throughout the facility and measured outside the required range of 105-120 degrees F, the measurements LPA observed were between 128.9-150.3 degrees F, citation issued. Storage areas for cleaning solutions, toxins, knives, and hazardous items were observed to be locked area inaccessible to clients, however, during tour LPA observed there to be unlocked scissors in building 6, citation issued.
Client Records-Incident Reports: Client files are kept in a secure location within the staff office and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA observed 6 client files during today’s visit with no issues.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Services: Medication is stored in the office/medication room. During todays visit, LPA reviewed 5 clients’ medication (reviewed from 12:50pm-1:15pm) and observed the following discrepancies: R1 and R2 had missed AM medication for today 7/17/26 and R3 had a missed medication for 7/16/26; upon arrival to the facility LPA observed there to be no staff in building 5 where the office/medication room is located, the door to the medroom was unlocked and clients were approaching the door, medication was visibly seen from the half door to be in an unlocked med cart, with exposed medication sitting on top and medication cabinets were also unlocked; LPA observed that staff are pre-dispensing medications in separate containers/small cups for each medication time (morning, noon, evening and night), citations issued.
Incidental Medical & Dental: Staff that assist with medication had proper training in their personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last emergency/fire drill was conducted on 4/29/2026.
Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques.
Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on 809D pages. Exit interview was held and a copy of the report was provided to Administrator.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 07/17/2026 03:27 PM - It Cannot Be Edited


Created By: Tena Herrera On 07/17/2026 at 02:46 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: C.M.A.
FACILITY NUMBER: 191591729

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as during medication review LPA observed R1 and R2 had missed AM routine medication for today 7/17/26 and R3 had a missed routine medication for 7/16/26, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2026
Plan of Correction
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During visit Administrator contacted pharmacy and it was explained that residents were ok to miss the medications without any serious effects and to proceed administering the medication per doctors orders.
Licensee/Administrator to have all staff that assist with medications re-trained for medication administration and provide a copy of the training log with list of participants and their signatures LPA by 7/27/26. tena.herrera@dss.ca.gov
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as upon arrival to the facility LPA observed there to be no staff in building 5 where office/medication room is located, door to the medroom was unlocked, clients were approaching the door, medication was visibly seen from the unlocked half door to be in an unlocked med cart, with exposed medication sitting on top, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2026
Plan of Correction
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During visit Adminstrator borrowed another staffs medroom keys to keep door locked, it was explained that Administrator has lost her set of keys and left the door unlocked when she walked out.
Licensee/Administrator will put a new lock on door and provide staff that need the key a new key, additionally a training must be provided to staff on how they will endusre medication room will remain locked at all time. Proof is to be emailed to LPA by 7/27/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Tena Herrera
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
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)
Page: 2 of 6
Document Has Been Signed on 07/17/2026 03:27 PM - It Cannot Be Edited


Created By: Tena Herrera On 07/17/2026 at 02:46 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: C.M.A.
FACILITY NUMBER: 191591729

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as it was observed that Health screening for S3 is blank with no physician signature and Health screening for S6 does not have staffs name which makes it difficult to confirm if health screening is for that particular staff, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2026
Plan of Correction
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Licensee/Administrator to have obtain a new Health Screening for S3 and S6 and email a copy of the completed health screening with negative TB results to LPA by POC due date. tena.herrera@dss.ca.gov
Type B
Section Cited
CCR
80075(k)(6)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (6) No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as during medication review LPA observed that staff are pre-dispensing medications in separate containers/small cups for each medication time (morning, noon, evening and night), which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2026
Plan of Correction
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Licensee/Administrator to review the regualtion/requirement and develop a plan on how they will ensure that medications will not be transferred between containers moving forward, plan is to be emailed to LPA by POC due date. tena.herrera@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Tena Herrera
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2026


LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 07/17/2026 03:27 PM - It Cannot Be Edited


Created By: Tena Herrera On 07/17/2026 at 02:46 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: C.M.A.
FACILITY NUMBER: 191591729

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on observation, the licensee did not comply with the section cited above as during tour LPA observed there to be unlocked scissors in building 6 that were on a desk with clients walking though the area, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2026
Plan of Correction
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During visit Administrator removed the scissors and placed them in a locked cabinet so they were no longer accessible to the clients in care.
Licensee/Administrator to conduct a training for all staff that explains how to keep items that could pose a danger if readily available to clients in secured areas that are inaccessible to clients. a copy of the training log with participant names and signatures is to be emailed to LPA by POC due date.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as hot water temperature in Bldg 1 measured at 150.1, temp in Bldg 3 meausred at 145.6, temp in bldg 2 measured at 128.9 and water temp in bldg 6 measured at 137.5, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2026
Plan of Correction
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During visit Administrator lowered the water heater temperatures.
Administrator/Licensee to monitor the hot water temperature for the next 3 days (morning,afternoon,night), maintain a waterlog for each time they measured the hot water in each building, all readings must be within the required range and a copy of the waterlog must me emailed to LPA by 7/21/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Tena Herrera
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6