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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601823
Report Date: 10/27/2023
Date Signed: 10/27/2023 03:43:03 PM


Document Has Been Signed on 10/27/2023 03:43 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:DELIGHTFUL AGING IFACILITY NUMBER:
198601823
ADMINISTRATOR:TAMANA MEHTAFACILITY TYPE:
740
ADDRESS:9223 BROOKSHIRE AVENUETELEPHONE:
(562) 622-3686
CITY:DOWNEYSTATE: CAZIP CODE:
90240
CAPACITY:6CENSUS: 6DATE:
10/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Hiransha Keerthisinghe - AdministratorTIME COMPLETED:
03:57 PM
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Licensing Program Analyst (LPA) Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPA Mora met with Hiransha Keerthisinghe (Administrator) and explained the reason for the visit. The facility is licensed to serve six non-ambulatory residents ages 60 and over and may retain up to six hospice residents. The facility is operating within the scope of its license.

A tour of the single-story facility included: 4 resident bedrooms, 1 staff bedroom, 3 resident bathrooms, living room, kitchen, dining area, front yard, backyard, and de-attached garage. LPA and Hiransha Keerthisinghe toured the facility and the following was observed: sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Auditory devices were seen on all exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in the residents’ bathrooms and measured at 105.2, 106.3, and 106.1 degrees F which is within the required 105 - 120 degrees F. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. The shower has non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have enough closet space. Resident beds have the required linen and the linen is in good condition. There is extra clean linen and towels in each bedroom. Smoke detectors were observed in each room and throughout the facility and are properly operating. A carbon monoxide was observed in the kitchen and it is properly operating. A fire extinguisher was observed in the hallway which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are kept locked in a kitchen cabinet. Chemicals and cleaning supplies are kept locked under the kitchen sink. First Aid kit was fully stocked with current manual and it is kept locked in the medication cabinet. The front and backyard are well maintained. There is a shaded seating area for the residents located in the backyard. There are no bodies of water at the facility. Passageways and exits are free of obstruction.

Residents medication are centrally stored in a locked living room cabinet. Residents and staff files are centrally stored in a living room cabinet. LPA reviewed medication for 6 of the residents and observed that medications are documented properly and given as prescribed. LPA reviewed files for all 6 residents and 5 staff. No deficiencies were found with the files. (Continued to LIC 809-C)

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DELIGHTFUL AGING I
FACILITY NUMBER: 198601823
VISIT DATE: 10/27/2023
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LPA observed administrator certificate for Hiransha Keerthisinghe with an expiration date of 05/12/2024. LPA interviewed 2 staff and 2 residents. Facility has a valid liability insurance.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report were provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC809 (FAS) - (06/04)
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