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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320363
Report Date: 08/25/2023
Date Signed: 08/25/2023 03:01:43 PM

Document Has Been Signed on 08/25/2023 03:01 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BUN CIRCLE SENIOR CARE HOMEFACILITY NUMBER:
198320363
ADMINISTRATOR:ABEYSINGHE, NILUSHAFACILITY TYPE:
740
ADDRESS:21504 GRACE AVETELEPHONE:
(323) 407-0401
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 0DATE:
08/25/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Binu KandagedonTIME COMPLETED:
03:15 PM
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On 8/25/2023, Licensing Program Analyst (LPA) Elvira Gonzalez and Licensing Program Manager (LPM) Stephanie Cifuentes conducted an announced pre-licensing continuation visit to this home. LPA and LPM were greeted by administrator Binu Kandagedon and explained the purpose of today’s visit. LPA and LPM were given access to the facility.

A Fire Clearance inspection was conducted on 4-19-2023 and approved for a capacity for five (5) non-ambulatory and one (1) for bedridden. Facility has a dementia care plan on file with the department and their fire clearance did not indicate if outer perimeter gate can be locked to create a secure perimeter for residents as needed when facility is offering dementia care.

On 8/17/2023 fire clearance was approved for five (5) non-ambulatory and one (1) for bedridden with delayed egress/secured perimeter for outer gate.

Component III Orientation: Component III was completed with the Applicant during the Pre-Licensing visit on 8/25/2023. Information was provided about how to operate the facility within substantial compliance. When the applicant was asked if she understood Title 22 Regulations he responded in the affirmative.

An exit interview was conducted, and a copy of this report has been furnished to administrator. LPA Gonzalez will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) 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.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2023
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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