198603339-9-28-2021-28-AS-LHIS-C7HQZH-20211005123647

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603339
Report Date: 09/28/2021
Date Signed: 09/28/2021 04:01:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/23/2021 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210923081002

FACILITY NAME:	PRIMECARE BELLFLOWER		FACILITY NUMBER:	198603339
ADMINISTRATOR:	KEERTHISINGHE, HIRANSHA S		FACILITY TYPE:	740
ADDRESS:	10245 TRABUCO STREET		TELEPHONE:	(562) 202-9669
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY:	6	CENSUS: 5	DATE:	09/28/2021
		UNANNOUNCED	TIME BEGAN:	01:28 PM
MET WITH:	Hiransha Keerthisinghe, Administrator		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Facility did not provide a copy of the resident's records to the resident's representative in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial complaint visit to investigate the above allegation.The purpose of the visit was discussed with caregiver staff Lorna Montemayor. Administrator Hiransha Keerthisinghe arrived shortly after.

The investigation consisted of the following: A tour of the interior and exterior physical plant was conducted. Residents (R2- R4), Licensee/Administrator staff (S1), and staff (S2-S3) were interviewed. Resident (R1) was discharged from facility on July 9, 2021 and was not interviewed. An interview was attempted with cognitively impaired resident. Resident (R1's) file documents were obtained [Physician Report, Preplacement Appraisal, Admission Agreement, Physician Order Sheet, Medication Administration Record (MAR), Administrator Log notes, discharge notice, incident report, resident roster, and LIC 500 Personnel Report.

See LIC 9099C for report continuation.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210923081002

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 09/28/2021

NARRATIVE

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Allegation: "Facility did not provide a copy of the resident's records to the resident's representative in a timely manner." Based on records review the findings indicate that on September 13, 2021 licensee received a letter requesting resident (R1's) file record documents. Per staff interviews, resident (R1) lived at the facility from June 26, 2021 - June 29, 2021. The resident was discharged on July 9, 2021 and passed away on July 14, 2021.

Administrator stated that resident (R1's) records were sent via Overnight Express on September 17, 2021. Per California Health and Safety Code section 1569.269(a)(21) resident and or responsible party shall "have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies."

Based on document review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to Title 22, Division 6 Health and Safety Code.

An exit interview was conducted with Administrator Hiransha Keerthisinghe. A copy of the report an appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210923081002

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/28/2021 Section Cited HSC 1569.269(a)(21)	1 2 3 4 5 6 7	Enumerated rights; severability. Residents of residential care facilities for the elderly shall have all of the following rights: To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. This requirement was not met by evidence of:	1 2 3 4 5 6 7	Administrator provided copies of resident (R1's) file records on September 17, 2021. A copy of the overnight receipt was provided to LPA. Deficiency is cleared.
	8 9 10 11 12 13 14	Based on records review resident (R1's) responsible party requested resident records on September 13, 2021. Licensee provided resident records on September 17, 2021, exceeding the 2 working days per health and safety code of regulations.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021

LIC9099 (FAS) - (06/04)

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