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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320186
Report Date: 06/24/2023
Date Signed: 06/24/2023 03:52:12 PM


Document Has Been Signed on 06/24/2023 03:52 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:GOLDEN EDEN IIIFACILITY NUMBER:
198320186
ADMINISTRATOR:PAMINTUAN, MART HYSAMFACILITY TYPE:
740
ADDRESS:2602 OSTROM AVENUETELEPHONE:
(323) 441-3691
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY:6CENSUS: 6DATE:
06/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:52 AM
MET WITH:Karla Stein TIME COMPLETED:
03:57 PM
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On 06/24/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Karla Stein. LPA explained the purpose of today’s visit. The facility is licensed to operate for (6) ambulatory of which (6) maybe non-ambulatory elderly adults ages 60 and above. Currently, the facility has (1) hospice residents in care. The facility is approved for (2) hospice resident.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (6) residents' rooms, (3) bathrooms, a living area, a dining area, a kitchen, an outside seating area, and a garage used for storage.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 106.8 – 114.4 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. The facility maintained an emergency food and water supply. Fire extinguishers were charged. A review of the Medication Records Administration (MAR) was observed to be maintained in place.

(Evaluation Report continues LIC 809-C)
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN EDEN III
FACILITY NUMBER: 198320186
VISIT DATE: 06/24/2023
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 06/09/23 and the earthquake drill on 06/09/23. The facility had operational smoke and carbon monoxide in bedrooms and common areas.

An audit of resident #1-#6 (R1-R6) service files and staff #1-#4 (S1-S4) personnel files revealed to be complete. The facility does not handle resident’s finances. Interviews were conducted with (6) residents and (3) staff. The facility has the current administrator's certification on file for Karla Stein #6025974740 Exp. 03/22/2025 and Mart Pamintuan #6019786740 Exp. 05/23/2024.

The annual license fees are overdue, and an invoice copy is left with Karla Stein.

No deficiencies during this inspection visit.

An exit interview was conducted with Karla Stein and a copy of the report was provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2023
LIC809 (FAS) - (06/04)
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