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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603282
Report Date: 12/19/2023
Date Signed: 12/19/2023 05:06:24 PM


Document Has Been Signed on 12/19/2023 05:06 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: DATE:
12/19/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:TIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced case management continuation visit to continue the required- 1 year visit focusing on CARE Tool. LPA Calderon joined LPA Jewel Baptiste at 2:30pm to complete a pre licensing inspection for a Change of Ownership. LPA upon arrival met with Administrator Thomas Trice and 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 4 (four) residents on hospice. During time of visit there were (1) bedridden and (1) hospice resident, the facility has an approved Dementia Care Plan in place.

During today's visit LPA observed, reviewed, and inspected the following:

Training's: Staff Training was conducted, Bedridden training documentation was not present at the facility. Fire Drill & Smoke Detector Record Training was conducted on: 12/18/23.

Medication: Medication review was completed by LPA Baptiste, no deficiencies noted.

Resident Files: LPA reviewed all client files, no deficiencies noted.

During today's visit deficiencies were cited. See LIC 809-D. An exit interview was conducted and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023
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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Document Has Been Signed on 12/19/2023 05:06 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: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87606(f)(3)
Care of Bedridden Residents
(f) To accept or retain a bedridden person, a facility shall ensure the following: (3) Staff records include documentation of staff training specific to Care of Bedridden Residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview with Licensee KEERTHISINGHE, HIRANSHA, record review during staff file review facility staff were unable to provide LPA with bedridden training documentation, the licensee did not comply with the
POC Due Date: 01/08/2024
Plan of Correction
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Facility Staff (Licensee / Administrator) will submit training for staff who assist with bedridden client. Regulation 87606 will be used as guidance for bedridden training.
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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023
LIC809 (FAS) - (06/04)
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