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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603719
Report Date: 04/18/2025
Date Signed: 04/18/2025 04:06:16 PM

Document Has Been Signed on 04/18/2025 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PRIMECARE DOWNEYFACILITY NUMBER:
198603719
ADMINISTRATOR/
DIRECTOR:		KEERTHISINGHE, HIRANSHAFACILITY TYPE:
740
ADDRESS:9223 BROOKSHIRE AVETELEPHONE:
(562) 286-3516
CITY:DOWNEYSTATE: CAZIP CODE:
90240
CAPACITY: 6CENSUS: 6DATE:
04/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Marianela Campos, CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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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
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PRIMECARE DOWNEY
FACILITY NUMBER: 198603719
VISIT DATE: 04/18/2025
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  • 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
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PRIMECARE DOWNEY
FACILITY NUMBER: 198603719
VISIT DATE: 04/18/2025
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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.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4