<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603976
Report Date: 07/21/2026
Date Signed: 07/21/2026 11:44:41 AM

Document Has Been Signed on 07/21/2026 11:44 AM - 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 ASSISTED LIVINGFACILITY NUMBER:
198603976
ADMINISTRATOR/
DIRECTOR:		KEERTHISINGHE, HIRANSHAFACILITY TYPE:
740
ADDRESS:17800 WOODRUFF AVE, STE FTELEPHONE:
(562) 286-3516
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 30CENSUS: 0DATE:
07/21/2026
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:51 AM
MET WITH:Hiransha Keerthisinghe - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 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) Tena Herrera conducted an announced visit and met with Administrator Hiransha Keerthisinghe for the purpose of conducting a Pre-Licensing Inspection / Component III visit. The facility has an approved fire clearance to be licensed to serve 4 Ambulatory Residents in rooms 101,110,112, 16 Non-Ambulaotry Residents in rooms 103,104,105,113, 114,115,116.117,118 10 Bedridden Residents in rooms 106,107,108,111,119. The facility is a single story building that includes: 17 resident rooms (of which 7 rooms have a private half bath), 2 shower rooms, 4 full bathrooms, 1 visitor restroom, kitchen, dining area, activity room, administrator office, conference room, staff break room, reception area, lobby, linen supply closet, medication closet, emergency supply room, generator area, and laundry room.

The physical plant was toured inside and out alongside and LPA utilized the Pre-Licensing Inspection Tool.


The following was observed/inspected
· Bedrooms are equipped with one bed, proper bedding, night-stand, chair, sufficient lighting, appropriate closet and drawer space.
· Bedrooms are large enough to allow for easy passage between and comfortable for usage of beds and other required items of furniture.
· Bedridden rooms had the 2 required exits, with door chimes that were tested and operable
· Sufficient supply of linens available to permit weekly changing and are stored in linen storage cabinet.
· Sufficient personal hygiene supply available.
· Laundry machine (wash/dryer) observed and operable.
· The bathrooms were toured and had working toilets/wash basin, showers had the required non slip mats, gab bars were observed near toilets and showers. (Continued on 809-C)
David Sicairos
Tena Herrera
DATE: 07/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 3
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 ASSISTED LIVING
FACILITY NUMBER: 198603976
VISIT DATE: 07/21/2026
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
26
27
28
29
30
31
32
· There are enough bath towels, hand towels and wash cloths.
· Smoke Detectors and Carbon monoxide detectors are interconnected approved in the Fire Clearance, and facility has an emergency fire sprinkler system.
· Fire extinguishers were observed and charged.
· Cleaning solutions are stored in a locked closet and sharps/knives are securely locked in kitchen and inaccessible.
· Kitchen cabinets, refrigerator/freezer, oven, microwave, dishwasher are in working condition, clean and sanitary.
· Food Menu Samples observed.
· Sufficient dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair.
· There is a designated space for Medications to be locked and inaccessible to residents.
· Resident and Staff files will be stored in a locked closet.
· First Aid Kit was observed with manual.
· Physical plant is in good repair, building and grounds are free from hazards, window screens are in good condition.
· There are two patio areas that are shaded to accommodate residents, no bodies of water observed.
· Hot water temperature measured between 109.6 and 115.1 F and is within Title 22 regulation of 105-120 F.
· The property is equipped with central air and heating, temperature remains at comfortable temp.
· Variety of activity supplies was observed within the activity room.
· Each exiting door has a door chime, they were tested and operable.
· Rooms have call buttons, these were tested, demonstrated to LPA and operable.
· Activity calendar and food menu are posted.
· Ombudsman, Complaint Poster and Resident Rights signage are clearly posted.

Component III was also completed at the time of the visit and all required documents for Licensing were discussed. Facility met the physical plant requirements/ inspection as required per California Code of Regulations Title 22 Division 6.

An exit interview was conducted, and a copy of this report has been furnished to the Applicants. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026
LIC809 (FAS) - (06/04)
Page: 3 of 3