198320186-5-21-2021-11-AS-JJON-C38LLK-20210521085112

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320186
Report Date: 05/20/2021
Date Signed: 05/21/2021 08:52:14 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	GOLDEN EDEN III		FACILITY NUMBER:	198320186
ADMINISTRATOR:	PAMINTUAN, MART HYSAM		FACILITY TYPE:	740
ADDRESS:	2602 OSTROM AVENUE		TELEPHONE:	(323) 441-3691
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY:	6	CENSUS: 5	DATE:	05/20/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:11 PM
MET WITH:	Mart Pamintuan Director		TIME COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPAs) Jade Jordan, made an announced visit, and met with the Director Mart Pamintuan, Administrator Karla Stein to conduct a Pre-Licensing evaluation on Thursday, May 20th, 2021 at 01:00 pm. An application was submitted to Community Care Licensing Department (CCLD) on 02/18/2021 for an initial application to serve Individuals for the ages 60 years and older. The requested capacity is for six (6) non-ambulatory clients, zero (0) ambulatory clients, and zero (0) bedridden clients, a total capacity of six (6). Structure: The facility is a one-story family home in a residential neighborhood. There is a family room, Living room, attached Garage which holds an administrative office, laundry, and additional storage. There are two common bathrooms, ( of which both are wheelchair accessible), staff bathroom, kitchen, and backyard. Bedroom Residents: There shall be no more than two clients per bedrooms. Bedrooms #1-6 are for Non-ambulatory clients, Bedrooms are equipped with one bed, nightstand, chair, lamp, and overhead lightning. Bedroom Staff: No bedrooms are used for awake staff. Bathrooms: Two (2) common bathrooms have a working toilet, showers/bathtub with skid mat, and grab bars. There is two bathrooms that will accommodate non-ambulatory clients in a wheelchair. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, fitted sheet, blanket and bedspreads. Ample supply of linen is stored in hall closet.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN EDEN III	FACILITY NUMBER: 198320186
	VISIT DATE: 05/20/2021

NARRATIVE

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Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers are posted and readily available for review in living room area. Facility has a land line telephone located throughout the facility. There is Two (2) fully charged fire extinguishers that is located in hallway, and living room. it was serviced 03/21. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils will be stored. Ample food supply is stored in the kitchen and consists of the following: 2-day perishables, and 7-day non-perishables. Smoke Detectors/Carbon Monoxide(s): There are (9) electrical & connected smoke detectors; located in bedrooms, (3) carbon monoxide in the hall, fully operational. Appliances: Stove burners (gas or electric), oven, dishwasher, microwave, and washer/dryer are in working condition. There are two (2) refrigerators in the facility; one in the kitchen, the back up in the garage, both are in working condition. The facility is equipped with central heat/air conditioning; and there are (2) water heaters. One is in the hall towards garage, and another on the side of the home. Toxins: Cleaning supplies, and toxins will be stored in a locked cabinet in the kitchen, only accessible to staff. Water Temperature: Hot water was tested in bathroom #1, and temperature was 110.8 degrees which is within normal limits (105-120 degrees). Medication, First-Aid Kit & Book: Designated centrally stored medication will be locked and located in medication cabinet in the kitchen. Sufficient bandages, one (1) tweezer, one (1) thermometer, one (1) First Aid Manual, and one (1) pair of scissors. Clients & Staff Files: Designated area for files will be located in locked office file cabinet in garage. Applicant will not handle cash resources of clients. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the client's use, commensurate with the plan of operation. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance was approved on 04/15/21 does advise of any delayed egress features and/or any locked perimeters.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN EDEN III	FACILITY NUMBER: 198320186
	VISIT DATE: 05/20/2021

NARRATIVE

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Component III:
Component III was completed at the Pre-Licensing on Thursday, 05/20/2021 at 3:00 pm. Information provided about how to operate the facility within substantial compliance. The following individuals, Mart, Karla participated. When the applicant and administrator were asked if they have understood Title 22 they responded in the affirmative.

During the pre-licensing inspection there were no items observed which did not comply with applicable laws and regulations.

An exit interview was conducted, and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

LIC809 (FAS) - (06/04)

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