198603339-6-20-2024-28-AS-THEA-D6ERND-20240620131009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603339
Report Date: 06/20/2024
Date Signed: 06/20/2024 01:10:25 PM

Document Has Been Signed on 06/20/2024 01:10 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: 4	DATE:	06/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:14 AM
MET WITH:	Jeneffer Reyes - Office Manager/DSP		TIME COMPLETED:	01:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Office Manager/DSP Jeneffer Reyes and the purpose for today’s visit was explained. Shortly after Administrators Mike and Hiransha Keerthisinghe arrived and assisted LPA with the inspection. The facility is licensed to serve 1 ambulatory and 5 non-ambulatory residents ages 60 and above, one of which may be bedridden (room #4 is approved for bedridden resident). Facility has a hospice waiver for 2 (currently only 1 resident is receiving Hospice services).

The facility is a single-story home located in Bellflower, Ca. A tour of the facility includes: living room, dining area, kitchen, 4 bedrooms, 3 bathrooms (2 of which are private baths), attached garage with laundry, and front/back yard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and the initial visit and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.
Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan, Bedridden and Dementia included in Plan of Operation, and facility maintains the required liability insurance.
Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. (continued on 809-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

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: 06/20/2024

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Physical Plant & Environment Safety (continued):
All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to residents, however, during tour LPA noticed a disinfectant that was unlocked in bathroom sink cabinet to Room #1's private bathroom (details will be documented on 809-D).
Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency.
Personnel Records-Training: Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, medication assistance, dementia and care for bedridden residents, other ongoing training are documented in a separate in-service binder. LPA reviewed 4 staff files with no issues observed. Administrator Km Dhammike Keerthisinghe ("Mike") certificate expires on 12/27/24.
Resident Records-Incident Reports: Resident files are kept in a secure location (within locked closet) and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 4 Resident Files with one issue observed within Resident #'1's file, the ambulatory status shows bedridden and resident is (according to administrator) non-ambulatory citation issued details found on 809-D.
Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman.
Planned Activities: Facility provides scheduled activities and have a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a closet and are in their original containers. LPA reviewed 4 residents’ medications and there were no issues observed.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last fire/disaster/earthquake drill was conducted on 05/20/2024.
Residents with Special Health Needs: Residents with railings on beds have proper doctor order for such railings within file. Facility maintains proper documentation for Hospice Services.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit will be documented on 809-D. Exit interview held, a copy of the report and appeal rights were provided to the Administrators Mike and Hiransha Keerthisinghe.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/20/2024 01:10 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: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as during tour LPA observed a large bottle of fabuloso (with disinfectant inside) under the sink in the client restoom (unlocked cabinet). This restroom is located between bedroom #1 and kitchen with two doors one that exits in kitchen and other door that enters bedroom. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/21/2024
	Plan of Correction
1 2 3 4	Staff Jeneffer immediatly removed disinfectant and stored with all other disinfectants in a locked cabinet Licensee/Administrator to conduct a training that covers proper storage of 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. All staff must complete training and a copy of the training materials and participant list is to be emailed to LPA by 7/8/2024. (tena.herrera@dss.ca.gov)

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: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/20/2024 01:10 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: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as R1's physician report indicates that resident is bedridden (resident currently resides in room #1 which is not cleared for bedridden residents), per administrator this is an error on physician report as resident is non-ambulatory not bedridden, this poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/08/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to forward updated physician report via email with correct ambulatory status to LPA by 7/8/2024. (tena.herrera@dss.ca.gov)

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: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC809 (FAS) - (06/04)

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