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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603339
Report Date: 07/14/2021
Date Signed: 07/14/2021 04:08:21 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) 202-9669
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY:6CENSUS: 5DATE:
07/14/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:07 PM
MET WITH:Hiransha Keerthisinghe - AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores conducted a case management visit during a complaint investigation visit on 7/14/21.

During the health and safety check conducted during the complaint investigation LPA observed the following: facility's kitchen sharps were kept on drawer next to stove and cleaning supplies kept in cabinet under sink , both have locks but do not lock properly and were not lock at the time of the visit. LPA checked rooms #1(R1),2(R2),3(R3),4(R4) each bedroom has all required bedding, and furniture. LPA observed full bed rails in R1,R2,R3,R4. LPA Flores reviewed Resident #1(R1),#2(R2)#3(R3), R4(R4),#5(R5) files and did not observed a physician's request for full rails, administrator stated to need to request from physician's. Medication for R1,R2,R5 was reviewed and facility had different PRN medication without a doctor's prescription for R3, and R5. Cleaning liquids were observed under Bathroom #3's sink, and were not under lock.

Based on the above observations, deficiencies will be cited under Title 22, Division 6, Chapter 8 on LIC 809D.

Exit interview was conducted with Hiransha Keerthisinghe, administrator and a copy of the report, LIC 809D, and appeal rights were provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
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 BELLFLOWER
FACILITY NUMBER: 198603339
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/15/2021
Section Cited

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87465 Incidental Medical and Dental: (e) For every prescription andnonprescription PRN medication... there shall be a signed, dated written order from a physician,... maintained in the residents file, and a label on the medication....
This requirement is not met as evidence by:
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Based on observation licensee did not ensure all PRN medication for R3, and R5 have a physician's prescription and label this poses an immediate Health, Safety, or Personal Rights risk for persons in care.
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Type A
07/15/2021
Section Cited

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87608 Postural Supports: (a) ... 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....

This requirement is not met as evidence by:
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Based on observation facility did not ensure to kept, or obtain a physician's request for full bed rails for 4 out of 5 residents which poses an immediate health, safety, or personal rights to the persons in care.
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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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2021
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 BELLFLOWER
FACILITY NUMBER: 198603339
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/15/2021
Section Cited

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87309 Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
This requirement is not met as evidence by:
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Based on observation facility did not ensure all sharps and chemicals were kept under lock at all times which poses an immediate health, safety, or personal rights risk for persons in care.
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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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3