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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602361
Report Date: 03/04/2024
Date Signed: 03/04/2024 10:15:14 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/10/2022 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20220110123454
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:
03/04/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Hiransha KeerthisingheTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Covid-19 masking protocols are not being followed.
Nurse is being impeded while trying to provide medical care to resident.
Resident was not accorded privacy while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nune Margaryan conducted a subsequent unannounced complaint visit to deliver findings to the above mentioned allegations. LPA met with Hiransha Keerthisinghe and explained the reason for the visit.
The investigation consisted of the following: On 01/13/22 and 02/23/24 interviews were conducted with the staff and residents. On 2/23/24 PT (Physical Therapist) who was visiting one of the residents (R2) at the facility also were interviewed. Staff and residents’ rosters were obtained, Residents and facility files were reviewed, and relevant documents were obtained.

Continue 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20220110123454
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
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 INC
FACILITY NUMBER: 198602361
VISIT DATE: 03/04/2024
NARRATIVE
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The investigation revealed the following: Regarding the allegation that Covid-19 masking protocols are not being followed, it was alleged: at the time of nurse visit Facility staff were not wearing mask.

The administrator and interviewed staff denied the above allegation and stated that all staff when there were mask mandates in order, the facility followed the most up to date regulations and staff always wear masks while working in the facility. Upon reviewing of training materials LPA observed that staff were trained and followed Covid guidelines / protocols for mask use. During the visit LPA observed all staff at the facility to be wearing face masks. Interviewed residents stated they have not witnessed staff not wearing masks and have no concerns about it.

Regarding the allegation that Nurse is being impeded while trying to provide medical care to resident, it was alleged: facility staff did not allow the nurse to see the resident and provide treatment without wearing full PPE.

The administrator and staff stated that during the Covid period staff tried their best to protect the residents. The administrator and staff stated that staff were trained and followed the Covid guidelines and protocols, and the facility procedure was to wear masks and gowns for all visitors before visiting the residents. The Administrator confirmed that nurses were not impeded while providing medical care to residents, however, were being requested to wear masks and gowns before entering facility / resident’s room. Staff interviews confirmed that medical staff / nurses were allowed in the facility and not impeded to provide medical care to residents. All interviewed residents stated that nurses or other medical staff were never impeded by facility staff while providing medical care to them.




Continue 9099C
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20220110123454
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
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 INC
FACILITY NUMBER: 198602361
VISIT DATE: 03/04/2024
NARRATIVE
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Regarding the allegation that Resident was not accorded privacy while in care, it was alleged that the resident was not provided privacy at the time of the nurse’s visit.

Interviewed Administrator and staff denied the allegation. The administrator stated that they and their staff always provide privacy to resident’s visitors and medical professionals / nurses. Administrator stated when a family members or medical professionals / nurses entered residents room be able to close the door to protect residents privacy rights. Interviewed staff stated that they always provided privacy for residents. Visitors and residents call the staff when they need assistance. Interviewed residents stated that facility staff provided privacy to them. At the time of visit LPA observed that medical professional / PT ( Physical Therapist) was in the R2's room to provide medical care to resident, and staff provided privacy to resident and PT.

Based on LPA observations, interviews conducted, and records review: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit Interview conducted, a copy of this report provided to Hiransha Keerthisinghe.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3