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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320363
Report Date: 09/26/2025
Date Signed: 09/26/2025 11:54:59 AM

Document Has Been Signed on 09/26/2025 11:54 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
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: 3DATE:
09/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:29 AM
MET WITH:Nilusha AbeysignheTIME VISIT/
INSPECTION COMPLETED:
11:59 AM
NARRATIVE
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On September 26, 2025, 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 are no hospice resident in care.

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 105.0 degrees F. A comfortable temperature was maintained in the facility 77 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 11/17/24 – 11/17/25 policy #0100336011-0

Evaluation Report Continues on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2025
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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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)
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Document Has Been Signed on 09/26/2025 11:55 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 09/26/2025 at 11:14 AM
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: 09/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(3)
87608 Postural Supports (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and review the licensee did not comply with the section cited above. LPA identified Resident #2 had full bed rails and did not have physician’s orders on file. Resident was not on hospice. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2025
Plan of Correction
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Licensee will ensure to review and adhere to Title 22 87608 Regulations. LIcensee will remove full bed rails for Resident #2 or submit a physician's orders authorization for full bedrails. Proof of correction must be submitted to ernand.dabuet@dss.ca.gov by 10/03/25.
Type B
Section Cited
CCR
87211(a)(1)(D)
87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency...of the occurrence of any of the events... (D) Any incident which threatens the welfare, safety or health of any...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's interviews conducted and record reviews, the Licensee failed to report incident R1 & R3 admittance for hospitalizations and plumbing repairs for the facilty. This violation poses a potential health and safety risk to all residents in care.
POC Due Date: 10/03/2025
Plan of Correction
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Licensee agrees that a Plan of Correction will be submitted to CCLD by 10/03/25 with Unusual Incident Reports LIC 624 involving (R1 & R3) hospitalization incidents and plumbing repairs to (CCL). POC must be fax to 424-544-1016 by 10/03/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2025


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: 09/26/2025
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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-#3 (R1-R3) service records and staff #1-#4 (S1-S4) personnel records. The facility is current on CCL annual dues. The facility has a current Administrator Certificate for Nilusha Abeysignhe #7022740740 effective: 07/07/2024 through 07/06/2026.

Deficiencies:
  • During file review of service records for Resident #1 and Resident #3, LPA observed medical records for both resident hospitalization for 10/09/24 and 05/06/25, and current plumbing issues to CCLD not reported.

  • LPA identified Resident #2 with full bed rails is not on hospice care and did not have physician's order for full bed rails.

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 Nilusha Abeysignhe, 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. *
NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC809 (FAS) - (06/04)
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