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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320363
Report Date: 09/10/2024
Date Signed: 10/01/2024 04:06:23 PM

Document Has Been Signed on 10/01/2024 04:06 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:BUN CIRCLE SENIOR CARE HOMEFACILITY NUMBER:
198320363
ADMINISTRATOR/
DIRECTOR:		ABEYSINGHE, NILUSHAFACILITY TYPE:
740
ADDRESS:21504 GRACE AVETELEPHONE:
(323) 407-0401
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 4DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:NILUSHA ABEYSINGHETIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 09/10/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Nilusha Abeysinghe. LPA explained the purpose of today’s visit. The facility is licensed to operate for six non-ambulatory elderly resident ages 60 and above. The facility is approved for two (2) hospice waiver. Currently, there is one (1) hospice resident.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) residents' rooms, two(2) staff room, two (2) bathrooms, one (1) staff bathroom, a living area, a dining area, a kitchen, and an outside patio area.

LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. A water temperature of 106.0 degrees F. A comfortable temperature was maintained in the facility 73 degrees F.

LPA observed the facility to be sanitary and appropriately furnished during the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained adequately. The fire extinguishers were charged, and smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) was observed to be maintained in order. The facility has a current liability insurance effective 11/17/23 – 11/17/24 policy #0015022-0.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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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Document Has Been Signed on 10/01/2024 04:06 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 09/10/2024 at 03:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BUN CIRCLE SENIOR CARE HOME
FACILITY NUMBER: 198320363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA identified Staff #1-#6 did not have LIC 503 Health Screening and Staff #4, #5, #6 did not have TB Test Results on file. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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Licensee will adhere to Title 22 87412 and ensure that each staff have Health Screening LIC 503 on file along with TB Test Results. Proof of correction of a completed fire drill will be sent as proof to ernand.dabuet@dss.ca.gov by POC due date 10/10/24.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA identified staff #1-#6 had no traiing records completed on file. This vioation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2024
Plan of Correction
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Licensee will adhere to Health & Safety 1569.625 and ensure all staff that have direct care to residents must have completed medical training including dementia, postural support, and restricted health. Proof of correction of a completed fire drill will be sent as proof to ernand.dabuet@dss.ca.gov by POC due date 10/10/24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/01/2024 04:06 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 09/10/2024 at 03:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BUN CIRCLE SENIOR CARE HOME
FACILITY NUMBER: 198320363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA identified staff #1-#6 all did not have medication training completed on file. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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Licensee will adhere to Health & Safety 1569.69 and ensure all caregiver staff have completed medication training. Proof of correction of a completed certificates for staff #1-#6 will be sent as proof to ernand.dabuet@dss.ca.gov by POC due date 09/11/24.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA identified the facility had no record of emergency/fire dril conducted within the quarterly period. This violaton which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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Licensee will adhere to Health & Safety 1569.695 and ensure quarterly emergency fire drills are conducted with residents and staff. Proof of correction of a completed fire drill will be sent as proof to ernand.dabuet@dss.ca.gov by POC due date 10/10/24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BUN CIRCLE SENIOR CARE HOME
FACILITY NUMBER: 198320363
VISIT DATE: 09/10/2024
NARRATIVE
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During the visit, LPA observed the facility's infection control practices. LPA observed staff followed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. Posters mandated for inspection control were posted.

An audit of residents #1-#4 (R1-R4) service records and staff #1-#6 (S1-S6) personnel records. The facility is current on CCL annual dues. The facility has a current Administrator Certificate for Nilusha Abeysignhe #7022740740.

Deficiencies:
During record reviews of staff files for staff #1-#6 were incomplete. LPA identified staff #1-#6 did not have completed medical training which included, dementia care, restricted health conditions, postural supports and medications. LPA observed the facility has not conducted required Quarterly Emergency/Fire Drills no proof of Emergency Drills on file. LPA identified Staff #1-#3 did not have LIC 503 Health Screening.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

An exit interview conducted with Ethe Monterroso and a copy of the report is provided.



Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC809 (FAS) - (06/04)
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