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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603339
Report Date: 07/27/2021
Date Signed: 07/27/2021 12:37:20 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:
07/27/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:52 AM
MET WITH:Hiransha Keerthisinghe - Administrator TIME COMPLETED:
01:00 PM
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced plan of correction (POC) visit at the facility. LPA Flores met with and explained the reason for the visit.

LPA Flores conducted a case management visit on 7/14/21 and found the following deficiencies:

87465(e) Incidental Medical and Dental - PRN medications did not have labels on medication for Resident #3 and #5.
87608(a)(3) Postural Support - Half bed rails were observed in bedrooms #1, #2, #4, and #5.
87309(a)(1) Storage Space - cleaning chemical solutions and sharps were not kept under lock.

During today's visit LPA Flores observed bed rail request for Resident's in bedroom #1,#2, #3,#4, #5. PRN Medication for R#3 and R#5 were label with resident's and medicine information and administrator certify on LIC 9098 that all PRN medication will be label with a pharmacy label. Cleaning supplies and sharps locks were working properly and kept under lock and administrator certify in LIC 9098.

Deficiencies have been fixed and cleared.

Exit interview was conducted and a copy of the report and POC letters was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
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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