198320363-7-21-2023-11-AS-EGOZ-CTXV87-20230721161215

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320363
Report Date: 07/21/2023
Date Signed: 07/21/2023 04:12:41 PM

Document Has Been Signed on 07/21/2023 04:12 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	BUN CIRCLE SENIOR CARE HOME		FACILITY NUMBER:	198320363
ADMINISTRATOR:	ABEYSINGHE, NILUSHA		FACILITY TYPE:	740
ADDRESS:	21504 GRACE AVE		TELEPHONE:	(323) 407-0401
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	6	CENSUS: 0	DATE:	07/21/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Nilusha Abeysinghe		TIME COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 7/21/2023, Licensing Program Analyst (LPA) Elvira Gonzalez and Licensing Program Manager (LPM) Stephanie Cifuentes conducted an announced pre-licensing visit to this home. LPA and LPM were greeted by applicant Nulisha Abeysinghe and explained the purpose of today’s visit. LPA and LPM were given access to the facility. An application was submitted to CCLD on 03/04/2023 for an initial license application for a Residential Facility for the Elderly, ages 60 years and above. The applicant requested a capacity of six (6) individuals, of which maybe five (5) non-ambulatory, and one (1) bedridden. Structure: The home is a Five (5) bedroom, three (3) bathroom, one story home with detached garage situated in a residential neighborhood. The home includes a living, dining, kitchen, and laundry area. Living room fireplace had a bolted on screen. The living area included sectional seating. The kitchen has a refrigerator and stove. Passageways, walkways, and steps inside and out are free from obstructions. Bedrooms Residents: The facility has four (4) bedrooms for residents. There are four (4) bedrooms for non-ambulatory residents of which one is specific for bedridden. Two rooms include a bed, chair, nightstand. Two rooms had two beds, two chairs and two bedside tables. All bedrooms are equipped with ceiling lights and dressers, which comply with the requirement of 8 cubic feet of space. All rooms had closets for ample storage. Bedrooms Staff: Bedroom 5 is designated for staff. Evaluation Report Continues

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BUN CIRCLE SENIOR CARE HOME	FACILITY NUMBER: 198320363
	VISIT DATE: 07/21/2023

NARRATIVE

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Bathrooms:
The home has two (3) bathrooms, one of which is in the staff room. All bathrooms have a working toilet, washbasin, and shower with grab bars and non-skid mats.

Linens & Hygiene Supplies:
Beds have the required linen supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in the hall closet.

Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers. The exit plan and menu are posted and readily available for review throughout the home. There is one (1) fire extinguisher located in the kitchen mounted on the wall. Facility has a working telephone which was called by LPA and LPM and found to be operational. Emergency supplies and Personal Protective Equipment supplies are stored in the garage. The applicant as an approved Infection Control Plan on file.

Food Service:
Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked kitchen drawer. Food supply is adequately stored and consist of (2) day supply of perishables and a (7) day supply of non-perishables. The kitchen counters also had small appliances.

Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior space. Hardwired smoke detectors in all five (5) bedrooms and hallways. Carbon monoxide detector is in kitchen.

Toxins:
All toxins are locked and stored in hall closet, with a locked space under kitchen sink available as well.

Evaluation Report Continues

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC809 (FAS) - (06/04)

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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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BUN CIRCLE SENIOR CARE HOME	FACILITY NUMBER: 198320363
	VISIT DATE: 07/21/2023

NARRATIVE

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Appliances:
Kitchen appliances found to be within title 22 requirements. Home is equipped with central heaters and air conditioning systems.

Water Temperature:
The water temperature was found to be withing title 22 regulations throughout the kitchen and bathrooms.

Medications, First-Aid Kit & Book:
A first aid kit is stored in hallway and contained thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to residents. The resident's medications will be stored in a cabinet locked in the kitchen area and inaccessible.

Resident & Staff Files:
Records of staff and residents will be stored in cabinets off in the kitchen area.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, magazines, and other recreational materials for the resident's use all stored in the living room.

Pool/Jacuzzi & Pets:
There are no pets, jacuzzi, or pool on premises.

A Fire Clearance inspection was conducted on 4-19-2023 and approved for a capacity for five (5) non-ambulatory and one (1) for bedridden.

LPA Gonzalez and LPM Cifuentes noted the following correction needs to be made:

· Fire clearance does not indicate if outer perimeter gate can be locked to create a secure perimeter for residents.

An exit interview was conducted, and a copy of this report has been furnished to the applicant Nilusha Abeysinghe. LPA Gonzalez will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC809 (FAS) - (06/04)

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