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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603282
Report Date: 11/30/2021
Date Signed: 11/30/2021 04:09:11 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 INC - IIIFACILITY NUMBER:
198603282
ADMINISTRATOR:KEERTHISINGHE, HIRANSHAFACILITY TYPE:
740
ADDRESS:12033 CAMINO VALENCIATELEPHONE:
(562) 210-8055
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:6CENSUS: 4DATE:
11/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Staff / Adelyn Marano
and Administrator / Hiransha Keerthisinghe 		TIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with staff Adelyn Marano and explained the purpose of the visit. Administrator Hiransha Keerthisinghe arrived shortly after.
The facility is a single story home located in a residential area licensed to serve 1 (one) ambulatory, 5 (five) non-ambulatory residents ages 60 and over of which 1(one) may be bedridden, and facility is approved to retain 2 (two) residents on hospice. All mandated documents are posted in a prominent place. Administrator certificate expires 5/12/2022.
PA Nune Margaryan inspected the physical plant including but not limited to the kitchen, dining and living room, bedrooms, bathrooms, laundry area (located in the garage), and outside areas of the facility to ensure compliance with Title 22 regulations. The facility consists of 4(four) bedrooms, 2 (two) bathrooms living room, dinning room, kitchen, laundry area, and attached garage.

The following were observed / inspected:

  • The interior and exterior physical plant was inspected.
  • COVID-19 Infection Control 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. Visitor screening is in place.
  • The bathrooms are clean and operational w/grab bars and non-skid surface/mats in place. The hot water temperature was tested throughout the facility and maintained within the required range of 105-120*F.
  • Resident rooms are sanitary and had the required furniture and furnishings

Continued 809C

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

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 - III
FACILITY NUMBER: 198603282
VISIT DATE: 11/30/2021
NARRATIVE
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  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Sharps are locked in the kitchen and are inaccessible to residents.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.
  • Staff files were reviewed. Staff #1 (S1) is cleared but not associated to the facility.
  • Cleaning supplies and toxins are locked and are inaccessible to residents.
  • First Aid kits were inspected and were fully stocked.
  • Medications are centrally stored in a locked cabinet in the hallway.
  • The fire extinguisher observed to be fully charged. Smoke/carbon monoxide detectors were observed to be fully operational. The outdoor area was enclosed, and no bodies of water were observed.
  • Deficiency is cited. See LIC 809D.

Exit interview was conducted with Administrator Hiransha Keerthisinghe . A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 - III
FACILITY NUMBER: 198603282
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, Staff #1(S1) is cleared, but not associated to this facility, which poses an immediated health and safety risk to residents in care.
POC Due Date: 12/01/2021
Plan of Correction
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Licensee shall create an account with the State of California Guardian system and complete a transfer requests for Staff #1(S1) by tomorrow.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3