198603282-12-15-2023-28-AS-ACAN-CYK3FP-20231215171304

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603282
Report Date: 12/15/2023
Date Signed: 12/15/2023 05:13:23 PM

Document Has Been Signed on 12/15/2023 05:13 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 - III		FACILITY NUMBER:	198603282
ADMINISTRATOR:	KEERTHISINGHE, HIRANSHA		FACILITY TYPE:	740
ADDRESS:	12033 CAMINO VALENCIA		TELEPHONE:	(562) 210-8055
CITY:	CERRITOS	STATE: CA	ZIP CODE:	90703
CAPACITY:	6	CENSUS:	DATE:	12/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:			TIME COMPLETED:	05:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced Required- 1 year visit focusing on CARE Tool. LPA met with staff Caregiver Salvador Huerta and explained the purpose of the visit. Shortly after LPA met with Administrator Thomas Trice and later met with Licensee Hiransha 'Sha' Keerthisinghe to discuss the purpose of today's visit.

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. During time of visit there were(0) bedridden and (1) hospice resident.

LPA Calderon inspected the physical plant including but not limited to the kitchen, dining and living room, (4) bedrooms, (2)bathrooms, laundry area (located in the garage), and outside areas of the facility to ensure compliance with Title 22 regulations. Facility tour was conducted with Licensee Sha and Administrator Thomas Trice.

The following were observed, inspected and reviewed: The interior and exterior physical plant was inspected during time of visit.

Bathrooms: are clean and operational w/grab bars and non-skid surface/mats in place. Toilet in hallway bathroom was observed to have toilet seat missing. LPA observed bedroom #4 having dust build up in shower and cabinet and curtain having mildew. LPA was informed that visitors and staff use bathroom #4 located in residents room.
The hot water temperature was tested throughout the facility and maintained within the required range of 105-120*F.

(Continuation on 809C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

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
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: 12/15/2023

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Resident rooms: are sanitary, are furnished and have the appropriate linen, and mattresses are in good condition. Residents in room #4 have hospital beds and full bed rails and are not on hospice. Room #4 has peeling tiles/ floor, dented tiles/ floor and lifting up from the ground.
Kitchen: Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. Kitchen cabinets were observed to have crumbs, lint and dust. Kitchen title needs repair, LPA observed a crack tile at the entrance of the kitchen room. Sharps are locked in the kitchen and are inaccessible to residents. The fire extinguisher observed to be fully charged. Cleaning supplies and toxins are locked and are inaccessible to residents.

Files: Staff and resident files are kept locked in hallway closet. Staff files were reviewed and all documentation's were kept in place. Licensee's Administration certification expires: 5/12/2024.

Hallway: was observed to be clean, free of debris and obstructions. Extra supply of linen and bedsheets were observed either in resident rooms or hallway cabinets, sufficient amount observed. Medications are locked in hallway cabinet and First Aid kits were inspected and were fully stocked. Smoke alarms are interconnected with the carbon monoxide detectors. LPA tested devices and devices were operable. Fire Drill Date:11/17/23.
Outside: No bodies of water were observed, outside window seals were observed with spider webs, extra window glass placed against the facility building.
Garage: During time of visit LPA observed staff using door in resident bedroom #1 that leads to garage being used. Laundry machines located in garage.

During today's visit deficiencies were cited. See LIC 809-D. Due to insufficient time LPA Calderon will return at a later date, a copy of the report and appeal rights were provided to Administrator Thomas Trice

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/15/2023 05:13 PM - It Cannot Be Edited

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: 12/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)(C)

(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation interview with Staff Khmdhammike Keerthisinghe and Licensee Hiransha Keerthisinghe, the licensee/ facility did not comply with the section cited above in [3] out of [5] persons, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/19/2023
	Plan of Correction
1 2 3 4	Administrator will post a sign on door leading to garage in bedroom #1 to state not to be used by staff / visitors and a sign on bathroom door in residents room #4 to state: to be used by Residents in room #4 only and their visitors . (if resident's provide consent). Administrator will send photo to LPA.

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Bathroom #4 was observed with dusty cabinets and mildew on shower curtain. Kitchen tile broken, floor in resident room #4 was osberved to have tiles that dented when stepping on tiles and tiles lifiting up, and piling.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in [2] out of [5] persons, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/26/2023
	Plan of Correction
1 2 3 4	Administrator will replace tiles to ensure safety for residents, visitors and staff.

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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/15/2023 05:13 PM - It Cannot Be Edited

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: 12/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Residents in Bedroom #4 had full bed rails and hospital bed and both residents are not on hospice.
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in [2] out of [5] persons, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	Facility will remove bed rails and will get physican reports for half bed rails/ hospital bed for residents in room #4.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

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