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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602361
Report Date: 01/28/2022
Date Signed: 01/28/2022 12:40:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PRIMECARE FACILITY HOME INCFACILITY NUMBER:
198602361
ADMINISTRATOR:KEERTHISINGHE, HIRANSHAFACILITY TYPE:
740
ADDRESS:18603 JEFFREY AVETELEPHONE:
(562) 286-3516
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:6CENSUS: 6DATE:
01/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Hiransha Keerthisinghe, AdministratorTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPAs met with Administrator Hiransha Keerthisinghe and explained the purpose of the visit. There are 6 residents ages 60 and above. The The facility has a Dementia Waiver in place. A hospice waiver for 4 residents is in place. The facility is a single story home located in a residential neighborhood that is licensed for 6 non-ambulatory residents, of which 1 may be bedridden. It consists of 4 bedrooms, 2 bathrooms, living room, family room/dining area, kitchen, outdoor covered patio, and a detached garage with laundry area. The last fire drill was conducted on 1/20/22. Administrator certificate expires 10/9/2021.

The following were observed/inspected:
  • COVID-19 Infection Control screening and signs were observed in the entrance, common areas, hallways, and bathrooms. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. No health and safety issues were observed.
  • Facility has an approved COVID-19 Mitigation Plan.
  • Room #4 has been designated as a COVID-19 solation room if needed.
  • Three (3) centrally stored resident medication records were reviewed.
  • Staff were observed wearing a surgical mask.
  • Residents in care were not observed wearing masks, as it is not tolerated due to health issues.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A posted Emergency Disaster Plan was observed.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.
  • Staff and resident files were not reviewed during today's visit.


No deficiencies were cited.

Exit interview was conducted with Administrator Hiransha Keerthisinghe . A copy of the report was issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
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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