198603339-5-7-2026-28-AS-DSIS-DTYS9N-20260511134102

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603339
Report Date: 05/07/2026
Date Signed: 05/07/2026 12:52:37 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
04/30/2026 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20260430134658

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:	05/07/2026
		UNANNOUNCED	TIME BEGAN:	10:09 AM
MET WITH:	Hiransha Keerthisinghe - Administrator/Licensee		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Staff will not allow resident to be re-admitted to facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced initial 10-Day complaint investigation regarding the above allegations. LPA met with Administrator Hiransha Keerthisinghe and explained the purpose of the visit.

The investigation consisted of the following:

LPA obtained copies of Resident #1’s Admission agreement, Letter written to responsible party, Special Incident Report, Physicians Report, Hospice Plan of Care, and Copy of the facility’s Dementia Care within their Plan of Operation. LPA toured R1’s room and conducted interviews with 3 Staff (S1-S3) and 3 Witnesses (W1-W3).

(Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

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-20260430134658

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/07/2026

NARRATIVE

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The investigation revealed the following:

Allegation: Staff will not allow resident to be re-admitted to facility.

It is alleged that R1 was admitted to the hospital and has been ready for discharge as of 4/29/26, however, facility staff are not allowing R1 re-entry to the facility. LPA interviewed 3 staff and each confirmed that R1 is currently hospitalized due to increased behaviors and is being reassessed at an acute center, the 3 staff expressed the difficulties they have been experiencing providing care to R1 due to their increased behaviors and agitation. During file review LPA did not observe any incident reports documenting these increased behaviors, the only incident report received for R1 is dated 4/28/26 regarding this current hospitalization. LPA reminded Administrator/Licensee of the reporting requirements and that all unusual incidents must be reported to the department within the required time and to review the regulations for reporting requirements within the Title 22 Regulations. LPA interviewed 3 Witnesses and each confirmed that R1 was previously hospitalized at the local hospital but was discharged on 5/4/26 to an acute center. Interview with Administrator/Licensee revealed that R1 had been exhibiting increased behaviors and agitation, therefore, R1 was hospitalized on 4/28/26 to be reassessed, was discharged and admitted to an acute center for further assessment. Administrator stated that R1 has not been issued an eviction notice as they are waiting for the physicians assessment and for R1 to complete the 2 weeks of rehab to see if R1 will be needing a higher level of care or discharged back to the facility, in which Administrator confirmed if R1 is discharged back to the facility they will be allowed re-entry. LPA reminded Administrator/Licensee that if they wish to relocate R1 they would need to follow the procedures outline in Title 22 regulations, if eviction is needed then they must follow the proper eviction procedures that are also outline in the Title 22 regulations. LPA toured R1’s bedroom and belongings were still present in closet. Interview with W3 revealed that R1 is temporarily hospitalized at an acute center and no eviction notice has been given to R1.

Based on statements and interviews conducted with staff/witnesses, review of R1’s files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC9099 (FAS) - (06/04)

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