Primecare Bellflower

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Administrators Mike and Hiransha Keerthisinghe and explained the purpose for today’s visit. 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). 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 used the Compliance and Regulatory Enforcement (CARE) tools for todays visit and observed the following: Infection Control: The facility maintains the required Infection Control Plan. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan 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. Hygiene products are readily available for residents. The hot water temperature was tested and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, hazardous items are kept locked & are inaccessible to residents. Smoke detectors/carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. 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. (Continued on LIC809-C) Staffing & Personnel Records-Training: There appears to be sufficient staffing at all times in the facility. Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, medication assistance, and other ongoing training are documented in personnel files and in-service training file. LPA reviewed 3 staff files with no issues observed. Administrator Hiransha Keerthisinghe certificate expires on 5/13/2028. Resident Records-Incident Reports: Resident files are kept in a secure location (within staff room/office) 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 1 Resident File with no issues observed. 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. Incidental Medical & Dental: Medication is properly labeled, they are centrally stored in a closet and are in their original containers. LPA conducted medication review 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 5/2/26. Residents with Special Health Needs: Facility has a hospice waiver for 4 (currently there are 0 residents receiving Hospice services). Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 20, 2026

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

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 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.the state’s words, verbatim · CDSS document, May 7, 2026 · control 28-AS-20260430134658

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Jen Tuto and explained the purpose for today’s visit, shortly after Administrators Mike and Hiransha Keerthisinghe arrived and assisted. 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 there are 2 residents 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 maintains the required Infection Control Plan. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan and facility maintains the required liability insurance. Staffing: There appears to be sufficient staffing at all times in the facility. Personnel Records-Training: Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, medication assistance, and other ongoing training are documented in personnel files and in-service training file. LPA reviewed 4 staff files with no issues observed. Administrator Dhammike Keerthisinghe ("Mike") certificate expires on 12/27/2026. (Continued on LIC809-C) 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 residents. The hot water temperature was tested and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept locked and are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. Resident Records-Incident Reports: Resident files are kept in a secure location (within staff room/office) 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 no issues observed. 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. 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 5/15/25. Residents with Special Health Needs: There are Hospice Care Plans in place for the individuals receiving hospice care. There are residents in the facility that require the use of Oxygen and the proper signs were posted throughout the facility. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was emailed to primecare1970@gmail.com.the state’s words, verbatim · CDSS document, Jul 10, 2025

Type of visit: Required - 1 Year

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) 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.the state’s words, verbatim · CDSS document, Jun 20, 2024