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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603282
Report Date: 11/22/2022
Date Signed: 11/22/2022 02:09:11 PM


Document Has Been Signed on 11/22/2022 02:09 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
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: 5DATE:
11/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator Hiransha KeerthisingheTIME COMPLETED:
02:30 PM
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On 11/22/22 at 12:45 p.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Administrator, Hiransha Keerthisinghe who assisted with today’s visit.

The facility is licensed to serve 6 residents age 60 and over, 5 non- ambulatory, of which 1 may be bedridden. Hospice waiver for 4. The facility is a single-story building in a residential area, with a kitchen, living room/ office space, dining room, 4 bedrooms, 1 staff rest bedroom, 2-bathroom, garage, and backyard with shaded area. Fire extinguisher observed fully charged in dining room. There are smoke detectors/ Carbon monoxide located throughout the facility, tested and operational.



LPAs discussed infection control practices with administrator, toured the facility inside and out, reviewed food supply, reviewed staff files, and reviewed resident medications.

Report continued 809c
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022
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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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: 11/22/2022
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Bedrooms have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. LPA toured the kitchen and observed 7 days of perishables and 2 days nonperishable. The front and backyard are well maintained. The resident bathrooms are clean, and showers have non-skid materials. The hot water temperature measured at 107.2- 109.6 degrees F. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. LPA observed a sufficient supply of PPE in the garage. Infection control signs were observed throughout the facility. Medications reviewed for all residents and appears to be given as prescribed. Facility file reviewed revealed administrator certificate # 6039969740 expire 5/12/2024. Last emergency disaster drill 10/20/22.

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 was provided to Administrator.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2