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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603339
Report Date: 06/23/2020
Date Signed: 06/23/2020 04:48:48 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 BELLFLOWERFACILITY NUMBER:
198603339
ADMINISTRATOR:KEERTHISINGHE, HIRANSHA SFACILITY TYPE:
740
ADDRESS:10245 TRABUCO STREETTELEPHONE:
(562) 286-3516
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY:6CENSUS: 0DATE:
06/23/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Hiransha KeerthisingheTIME COMPLETED:
02:30 PM
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Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s Prelicensing visit was conducted with face time with applicant Hiransha Keerthisinghe. The facility has been granted by Bellflower Fire Department for 6 residents, 1 bedridden, 4 non ambulatory and 1 ambulatory on 5/12/2020.
The facility is a single story 4 bedroom, 3 bathroom home located in a residential neighborhood. All bedrooms are to be used for client bedrooms with Bedroom #1 - #3 are single occupancy and bedrooms #4 is shared and designated for bedridden.
Each bedroom has the required furniture, equipment and supplies, including but not limited to; storage space, lighting, beds, chair, linen supply, including mattress pads. There is a living room, dining room, kitchen. There is sufficient seating throughout the home. The first aid kit is complete. There are no bodies of water. There are no guns or weapons in the home. There are cabinets for medications and cleaning solutions, knives and toxins which are locked. All exits and passageways are free of obstructions. The yard is free of obstructions and debris. Smoke and carbon monoxide detectors are operational. There are alarm systems on all exits. Food supply is adequate. Gas and phone are operational. There are ramps surrounding the perimeter of the home. Administrator certificate expires 5/12/2022. All required documents are posted.
LPA conducted Component III with applicant.
No corrections needed for the prelicensing visit. LPA Day will notify CAU

A facetime exit interview was conducted with Administrator and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Shawna DayTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2020
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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