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Inspection visit

Routine inspection

PRIMROSE 3License 19760994712 citations on this visit
12 citations recorded

Inspector’s narrative

What the inspector wrote

On 10/07/25, at 8:15am., Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. Upon arrival, LPA met with Caregiver, Christopher Rogue de Guzman and disclosed the purpose of the visit. The administrator was called and stated they were out of town. LPA asked for the census, resident, and staff rosters. The facility tour started 8:55am Temperature of facility wall thermostat is observed and set to 76 degrees Fahrenheit. Medications -LPA observed medication stored in one (1) of the lower cabinets locked and secured in the kitchen area inaccessible to residents. Kitchen area was sufficiently stocked with seven (7) days of perishable and seven (7) days of non-perishable food. Sharps/Knives are stored and locked in one (1) of the cabinets in the kitchen on the right side of the sink. Toxins are kept secured and locked in one (1) of the cabinets under the kitchen sink inaccessible to residents. There is one (1) fire extinguisher located against the wall in the kitchen area on your left hand side fully charged and dated August 2025. There is a backyard which has outdoor furniture and grassy area for outdoor activities. There is no pool/and or bodies of water. LIC 809C-continued The garage is attached to the house and was observed to be locked and used to store toxins, extra storage. There is a washer and dryer located in this area. There is also one (1) refrigerator in the garage with extra food. Bedrooms/Bathrooms: There is five (5) bedrooms. One (1) bedroom is shared, three (3) bedrooms are single occupied. All five (5) bedrooms are properly furnished with proper lightning. The bathrooms have proper toiletry and grab bars. There is one (1) bathroom that is located by the entrance of the facility that is used by staff and residents. There are two (2) bedrooms that have private bathrooms. The bathroom temperature of the water are within regulations. It reads between 112.5-119 Degree Fahrenheit. Living and dining room furniture is accessible for six (6) residents and staff. There is a television, telephone line and enough seating for residents and staff. Furniture was observed to be in good condition and there is no fireplace. The smoke/carbon monoxide detectors are hardwired and interconnected and were tested. They were functional. Administrative: The Insurance plan is updated and expires on 07/2026, disaster plan, administrator certificate, Designation of facility responsibility, Admission Agreement, Personal Rights, resident rights signs are against the wall at the entrance of the facility, Infection Control and Disaster Plan, Ombudsman. Staff/Resident Files Reviewed : Six (6) resident files were reviewed and three (3) staff files were reviewed. Five (5) out of six (6) residents are missing functional capabilities form, five (5) out of six residents are missing resident appraisal form, One (1) resident is missing physician's report and tuberculosis, One (1) resident out of six (6) resident is missing pre-placement form, three (3) out of six (6) residents are missing needs and services plan. There are two (2) staff that are missing several forms such as Criminal Background/Fingerprinting, Personnel Record and education, training to provide medication to residents. An exit interview was conducted, several citation(s) were issued, appeals rights and a copy of this report was given to the caregiver that was present at the facility.

Citations

12 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 1569.618(a)Type B

    Based on the interview the licensee did not comply with the section cited above in not leaving someone responsible for the operation of the facility while being out of town which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 1569.625(b)(1)Type B

    Based on the record review the licensee did not comply with the section cited above in two (2) out of two (2) staff did not have proper/all of their training in their file which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 1569.69(a)(3)Type A

    Based on record review the licensee did not comply with the section cited above in two (2) out of two (2) staff did not have medication training in their file which poses an immediate health, safety or personal rights risk to persons in care.

  • 1569.695(e)(2)Type B

    Based on record review the licensee did not comply with the section cited above in three (3) out of six (6) residents did not have their needs and services plan which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87211(a)Type B

    Licensee reports required by licensing agency

    Based on the observation, interview and record review the licensee did not comply with one (1) person being sent to the hospital without notifying Community Care Licensing Department and another resident's death was also not reported to Community Care Licensing Department which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87355(d)(3)Type A

    Submit fingerprints for state and federal searches

    Based on the record review the licensee did not comply with the section cited above in one (1) out of two (2) staff did not have fingerprinting/criminal form in their file which poses an immediate health, safety or personal rights risk to persons in care.

  • 87412(a)(6)(A)Type B

    Based on the record review the licensee did not comply with the section cited above in two (2) out of two (2) staff did not have their a job application in their file thus showing their educational requirements which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87456(a)(2)Type B

    Perform a pre-admission resident appraisal

    Based on the record review the licensee did not comply with the section cited above in one (1) resident did not have their pre-placement pre-admission appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87458(a)Type B

    Obtain baseline medical assessment before resident admission

    Based on the record review the licensee did not comply with the section cited above in one (1) resident did not have their medical assessment/physician's report which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87458(c)(1)(8)Type B

    Based on the record review the licensee did not comply with the section cited above in which one (1) resident did not have their tuberculosis poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87506(b)(17)(B)Type B

    Based on the record review the licensee did not comply with the section cited above in five (5) out of five (5) residents did not have their functional capabiliies form in their file which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87506(b)(17)(E)Type B

    Based on the record review the licensee did not comply with the section cited above in five (5) out of five (5) residents did not have their resident reappraisal form in their file which poses/posed a potential health, safety or personal rights risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the October 7, 2025 inspection of PRIMROSE 3?

This was an inspection of PRIMROSE 3 on October 7, 2025. 12 citations were issued: 2 Type A (serious) and 10 Type B.

Were any citations issued to PRIMROSE 3 on October 7, 2025?

Yes, 12 citations were issued (2 Type A, 10 Type B). The first citation was for: "Based on the interview the licensee did not comply with the section cited above in not leaving someone responsible for t..."

What type of inspection was this?

This was an inspection. Inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.