Routine inspection·June 20, 2024

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Office Manager/DSP Jeneffer Reyes and the purpose for today’s visit was explained. Shortly after Administrators Mike and Hiransha Keerthisinghe arrived and assisted LPA with the inspection. The facility is licensed to serve 1 ambulatory and 5 non-ambulatory residents ages 60 and above, one of which may be bedridden (room #4 is approved for bedridden resident). Facility has a hospice waiver for 2 (currently only 1 resident is receiving Hospice services). The facility is a single-story home located in Bellflower, Ca. A tour of the facility includes: living room, dining area, kitchen, 4 bedrooms, 3 bathrooms (2 of which are private baths), attached garage with laundry, and front/back yard. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and the initial visit and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan, Bedridden and Dementia included in Plan of Operation, and facility maintains the required liability insurance. Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. (continued on 809-C) Physical Plant & Environment Safety (continued): All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to residents, however, during tour LPA noticed a disinfectant that was unlocked in bathroom sink cabinet to Room #1's private bathroom (details will be documented on 809-D). Staffing : There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records-Training : Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, medication assistance, dementia and care for bedridden residents, other ongoing training are documented in a separate in-service binder. LPA reviewed 4 staff files with no issues observed. Administrator Km Dhammike Keerthisinghe ("Mike") certificate expires on 12/27/24. Resident Records-Incident Reports: Resident files are kept in a secure location (within locked closet) and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 4 Resident Files with one issue observed within Resident #'1's file, the ambulatory status shows bedridden and resident is (according to administrator) non-ambulatory citation issued details found on 809-D. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities and have a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a closet and are in their original containers. LPA reviewed 4 residents’ medications and there were no issues observed. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last fire/disaster/earthquake drill was conducted on 05/20/2024. Residents with Special Health Needs: Residents with railings on beds have proper doctor order for such railings within file. Facility maintains proper documentation for Hospice Services. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit will be documented on 809-D. Exit interview held, a copy of the report and appeal rights were provided to the Administrators Mike and Hiransha Keerthisinghe.