Primecare Downey

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Christian Gutierrez conducted an annual continuation visit. Upon arriving at the facility, LPA met with caregiver Maria Campos and explained reason for visit. Administrator Hiransha Keerthisinghe and Assistant Administrator KM Dhammike Keerthisinghe arrived shortly after. On 04/27/26 LPA conducted an initial visit. During today's visit LPA Gutierrez reviewed the following CARE inspection tool domains: Staffing, Personnel Records/Staff Training, resident rights, resident records, health related services, and incidental medical services. Four (4) staff files were reviewed and included criminal clearance record, and health screening with TB. The required 20 hours of annual training was not completed. Five (5) of the six (6) resident files reviewed included physician reports and appraisal needs and service plan. R5 did not have updated physicians report LIC 602. Two (2) residents R4 and R5 were missing statements for shared room with a hospice resident. The medications are centrally stored and locked in a cabinet in living room. LPA reviewed medications for residents, and they are being administered as prescribed by the physician. Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Hiransha Keerthisinghe.the state’s words, verbatim · CDSS document, Apr 30, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced required annual visit. LPA met with Maria Campos, Caregiver and explained the reason for the visit. Administrator Hiransha Keerthisinghe and Assistant Administrator KM Dhammike Keerthisinghe arrived shortly after. The facility is licensed to serve six (6) non-ambulatory of which two (2) may be bed-ridden. Waiver granted for Hospice Care for six (6). Currently there are three (3) residents on hospice care and one (1) bed-ridden resident in room number 3. The facility is operating within the scope of its license. Facility is in a residential area of Downey. A tour of the single-story facility included: 4 resident bedrooms, 1 staff bedroom, 2 resident bathrooms, living room, kitchen, dining area, office area, front yard, backyard, and de-attached garage. LPA toured the facility and observed the following: Each resident bedroom has the required furniture and bedding. The Smoke detectors and carbon monoxide detectors were observed throughout the facility and are properly operating. The facility has one (1) fully charged fire extinguishers which is kept in living room. Cleaning supplies and toxic substances were observed to be inaccessible. LPA observed two knives and a pair of scissors in kitchen drying rack accessible to residents in care. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Facility had a sufficient supply of 2 days perishable & 7 days non-perishable foods. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The resident bathrooms have the required grabs bars and non-skid mats. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents in backyard. LPA observed a large hole on ramp leading to backyard. LPA reviewed Infection Control Plan and Emergency Disaster Plan. Last emergency drill was conducted on 02/02/2026. ***Due to time constraints, LPA was not able to complete the annual inspection for this facility. LPA will do a continuation of this inspection. ***Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Hiransha Keerthisinghe.the state’s words, verbatim · CDSS document, Apr 27, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs), Mayra Cota and Blanca Gonzalez, conducted an unannounced required annual visit. LPAs met with Marianela Campos, Caregiver and explained the reason for the visit and she assisted LPAs with the tour of the facility. Km Dhammike Keerthisnghe, Administrator, arrived shortly after. The facility is licensed to serve six (6) non-ambulatory of which two (2) may be bed-ridden. Waiver granted for Hospice Care for six (6). The facility is operating within the scope of its license. Facility is in a residential area of Downey. During the visit, LPAs toured the facility's indoor and outdoor environment, reviewed three (3) resident and (3) staff files, and conducted medication review. The facility is a single-story house which consists of a receiving area, office area, living room/dining area, kitchen/laundry closet, two (2) private resident bedrooms, two (2) shared resident bedrooms, one (1) staff bedroom, three (3) bathrooms, front and backyard and detached garage. During today’s visit, LPAs observed the following: Inside the home: Living room and dining area were observed clean and furniture is in good repair. Resident bedrooms have the required furniture such as dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen and mattress pads. Bed rails have the required physician orders in place. Rooms housing oxygen tanks have the required signs posted on the doors. Resident oxygen tanks have the proper stands and extra tanks are stored properly. ***Continue on LIC 809-C Sharps/knives, cleaning supplies and toxins were observed locked under kitchen sink and are inaccessible to residents. Sufficient supply of 2 day perishable and 7 day non-perishable food was observed. Food in the refrigerator and the cabinets was observed labeled and kept within expiration limits. Menus and Dietary Guidelines are posted in the kitchen. Kitchen appliances are clean and were operating at the time of visit. Three (3) full bathrooms were inspected and were observed clean. Showers have handrails and anti-slip mats. The water temperature was tested in all three (3) bathrooms and measured within the required 105 - 120 degrees F. Laundry closet was inspected and laundry appliances (washer and dryer) were observed to be working properly. Detergents are kept locked and inaccessible to clients. Sufficient personal hygiene products observed in storage cabinets throughout the facility. Outdoor environment: The front and backyard are well maintained and there are no pools or large bodies of water. Backyard has a patio area with outdoor furniture and shade. Patio furniture is in good repair and there is enough seating for clients in care. Garage is kept clean and free of clutter. Passageways and exits are free of obstruction. Disaster Preparedness and Emergency Intervention: Facility is equipped with back up generator which is located in the garage and a solar panel with a back up battery located in the backyard. Drills are conduced quarterly. Last fire/safety drill was conducted on 2/1/25. First Aid kit was reviewed and contained required tools and manual. Facility has one (1) fire extinguisher which was observed charged and operable. Emergency Disaster plan and Infection Control Plan reviewed and observed to be up to date. Facility is equipped with a fire sprinkler system and smoke and carbon monoxide detectors observed throughout the facility, were tested and working properly. ***Continues on LIC 809-C Medication Review: Medication is centrally stored and locked in medication cabinet. Client medication was reviewed and observed to be dispensed per physician's orders and documented accordingly on MAR. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies are cited today. Exit interview conducted with Km Dhammike Keerthisinghe, Administrator, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 18, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Mora conducted an announced Pre-Licensing visit using the CARE Tool. LPA met with Hiransha S Keerthisinghe (Licensee) and explained the reason for the visit. A change of ownership application was submitted to Community Care Licensing Department (CCLD) for a Residential Care For Elderly facility to serve six (6) non-ambulatory residents, of which two (2) may be bedridden in the age range of 60 and over. Facility is approved for 6 hospice waivers. A tour of the single-story facility included: 4 resident bedrooms, 1 staff bedroom, 3 resident bathrooms, living room, kitchen, dining area, office area, front yard, backyard, and de-attached garage. LPA and Hiransha Keerthisinghe toured the facility and the following was observed: sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Auditory devices were seen on all exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested and measured at 110.2 degrees F which is within the required 105 - 120 degrees F. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. The shower has non-skid material. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have enough closet space. Resident beds have the required linen and the linen is in good condition. There is extra clean linen and towels in each bedroom. Smoke detectors were observed in each room and throughout the facility and are properly operating. A carbon monoxide was observed in the kitchen and it is properly operating. A fire extinguisher was observed in the hallway which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are kept locked in a kitchen cabinet. Chemicals and cleaning supplies are kept locked under the kitchen sink. First Aid kit was fully stocked with current manual and it is kept locked in the medication cabinet. The front and backyard are well maintained. There is a shaded seating area for the residents located in the backyard. There are no bodies of water at the facility. Passageways and exits are free of obstruction. Residents medication are centrally stored in a locked living room cabinet. Residents and staff files are centrally stored in a office area cabinet. LPA reviewed medication for 6 of the residents and observed that medications are documented properly and given as prescribed. LPA reviewed files for all 6 residents and 5 staff. No deficiencies were found with the files. LPA observed administrator certificate for Hiransha Keerthisinghe with an expiration date of 05/12/2024. (Continued to LIC 809-C) No outstanding or pending items were observed by the LPA requiring additional pre-licensing visits. LPA will notify the assigned Centralized Applications Bureau (CAB) Analyst of the completed pre-licensing facility evaluation visit conducted, which included the Component III Orientation. Exit interview conducted and a copy of this report was provided to the licensee.the state’s words, verbatim · CDSS document, Mar 29, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 6 COMP II Participants: Hiransha Keerthisinghe (Licensee & Administrator) Interview Method: Virtual interview via Microsoft Teams On March 07, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Mar 7, 2024