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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603719
Report Date: 04/27/2026
Date Signed: 04/27/2026 02:12:11 PM

Document Has Been Signed on 04/27/2026 02:12 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:
04/27/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:57 PM
MET WITH:Hiransha KeerthisingheTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced required annual visit. LPA met with Maria Campos, Caregiver and explained the reason for the visit. Administrator Hiransha Keerthisinghe and Assistant Administrator KM Dhammike Keerthisinghe 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). Currently there are three (3) residents on hospice care and one (1) bed-ridden resident in room number 3. The facility is operating within the scope of its license. Facility is in a residential area of Downey. A tour of the single-story facility included: 4 resident bedrooms, 1 staff bedroom, 2 resident bathrooms, living room, kitchen, dining area, office area, front yard, backyard, and de-attached garage.

LPA toured the facility and observed the following: Each resident bedroom has the required furniture and bedding. The Smoke detectors and carbon monoxide detectors were observed throughout the facility and are properly operating. The facility has one (1) fully charged fire extinguishers which is kept in living room. Cleaning supplies and toxic substances were observed to be inaccessible. LPA observed two knives and a pair of scissors in kitchen drying rack accessible to residents in care. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Facility had a sufficient supply of 2 days perishable & 7 days non-perishable foods. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The resident bathrooms have the required grabs bars and non-skid mats. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents in backyard. LPA observed a large hole on ramp leading to backyard. LPA reviewed Infection Control Plan and Emergency Disaster Plan. Last emergency drill was conducted on 02/02/2026.

***Due to time constraints, LPA was not able to complete the annual inspection for this facility. LPA will do a continuation of this inspection. ***Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Hiransha Keerthisinghe.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2026
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 04/27/2026 02:12 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 04/27/2026 at 01:58 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PRIMECARE DOWNEY
FACILITY NUMBER: 198603719

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above LPA observed a large hole on outdoor ramp leading to backyard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2026
Plan of Correction
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Administrator will send LPA pictures of hole fixed or a work order from maintenance as to what is needed to fix hole.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above LPA obseved two knives and a pair of scissors in kitchen drying rack accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2026
Plan of Correction
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Administrator removed objects at time of visit. Administrator will conduct training on section 87309 (a) with staff and send LPA training material along with signatures of who attended.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2026


LIC809 (FAS) - (06/04)
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