198603339-7-31-2023-28-AS-BPEA-CUA5QX-20230731201012

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603339
Report Date: 07/31/2023
Date Signed: 07/31/2023 08:13:04 PM

Document Has Been Signed on 07/31/2023 08:13 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

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: 6	DATE:	07/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Hiransha Keerthisinghe - Administrator		TIME COMPLETED:	05:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Caregivers, Jeneffer Reyes and Jesusa Sargento and explained the purpose of the visit. At 1:52pm, Administrator, Hiransha Keerthisinghe arrived and assisted LPA with the inspection. There are six (6) residents of which three (3) are in hospice care residing in the home. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and the following was inspected during the evaluation: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor screening station at the entrance of the facility. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan and was reviewed. Facility has COVID-19 signage posted in the facility. Common area surfaces are being cleaned and disinfected on a regular basis. Bathrooms have liquid soap and paper towels. Staff are adhering to infection control requirements. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance is in place. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in the total annual aggregate is valid and will expire on 2/18/2024. The last fire Drill was conducted on 5/25/2023. Care and supervision to meet the residents needs was observed. Special equipment and supplies to meet the persons with special needs were observed. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood that is licensed for age range 60 and over, approved for one (1) ambulatory and five (5) non ambulatory, of which 1 may be bedridden. Non ambulatory in bedrooms 2, 3 & 4, bedridden in room #4. Facility has hospice waiver for 2. In July 2022, an approved hospice waiver for four (4) residents was granted. Facility consists of four (4) resident bedrooms, three (3) bathrooms, living room, office area, dining room, kitchen, backyard, patio area, and an attached garage. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has (1) fully charged fire extinguisher located in the living room. Fire extinguisher was last inspected on 7/11/2023. Cleaning supplies and toxic substances are inaccessible to clients. Hot water temperature readings measured 109.2 deg F in bathroom #1, 109.7 in bathroom #2 and 110.8 deg F in bathroom #3 which are within the required 105-120 degrees Fahrenheit. *CONTINUED ON LIC 809-C*

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PRIMECARE BELLFLOWER	FACILITY NUMBER: 198603339
	VISIT DATE: 07/31/2023

NARRATIVE

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Staffing: A total of seven (7) caregivers including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility.
Personnel Records-Training: Administrator certificate is valid and expires on 5/12/2024. Two (2) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings. One (1) staff has expired First Aid/CPR training.
Resident Records-Incident Reports: Three (3) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records, Restricted Health Care Plans and Hospice Records were reviewed.
Resident Rights-Information: Resident personal rights are posted. Physician orders for use of full/half bed rails were reviewed in residents files. LPA conducted (3) resident interviews.
Planned Activities: Information regarding Dementia is part of training for direct care staff and is included in the Plan of Operation.
Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean and well maintained). Two (2) residents have a special soft diet residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas. Plates, cups and utensils are kept cleaned and stored properly.
Incident Medical and Dental: All residents have Restricted Health Care Plan and Needs and Services Plan on file. Home Health personnel services the residents in the facility. Hospice and Home Health Nurses administer suppositories to the residents.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. The facility conducts emergency drill on a quarterly basis for all staff and residents.

Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview conducted with Administrator Hiransha Keerthisinghe. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/31/2023 08:13 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PRIMECARE BELLFLOWER	FACILITY NUMBER: 198603339
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review,, the Administrator did not comply with the section cited above in that during the staff file review staff #1 (S1) did not have a valid 1st Aid/CPR card on file which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 08/07/2023
	Plan of Correction
1 2 3 4	Administrator shall ensure all staff have current First Aid/CPR training on file. Administrator will submit a copy of Staff (S1) First Aid/CPR training certificate to CCL/LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/31/2023 08:13 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PRIMECARE BELLFLOWER	FACILITY NUMBER: 198603339
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(1)

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication reevaluation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the Administrator did not comply with the section cited above in that the facility staff administers PRN medications without proper label from the Pharmacy and not listed on the Physician's medication order which poses an immediate health, safety or personal rights risk to residents in care.
	POC Due Date: 08/01/2023
	Plan of Correction
1 2 3 4	Administrator will ensure that the PRN medications have the proper pharmacy label and shall contact the residents physicians to include the PRN medications on the physicians medicaiton order list. Administrator will submit proof to CCL/LPA by POC due date.

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/31/2023 08:13 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PRIMECARE BELLFLOWER	FACILITY NUMBER: 198603339
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(3)

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the Administrator did not comply with the section cited above in that the facility staff administered eight (8) medications for Resident #1 for a.m. cycle but was not recorded on MAR properly which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/01/2023
	Plan of Correction
1 2 3 4	Administrator will ensure medication provided to the residents is on cycle and record properly by staff on Medication Administration Record (MAR) sheet and re-train staff on medication. Proof of training signed and dated by staff shall be submitted to CCL/LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

LIC809 (FAS) - (06/04)

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