198320289-8-21-2023-11-AS-EDAT-CUWPFB-20230821111628

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320289
Report Date: 08/19/2023
Date Signed: 08/21/2023 11:16:57 AM

Document Has Been Signed on 08/21/2023 11:16 AM - 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 II		FACILITY NUMBER:	198320289
ADMINISTRATOR:	STEIN, KARLA		FACILITY TYPE:	740
ADDRESS:	5849 E. WALTON STREET		TELEPHONE:	(323) 441-3691
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY:	6	CENSUS: 5	DATE:	08/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:41 PM
MET WITH:	Karla Stein		TIME COMPLETED:	03:59 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	On 08/19/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met administrator Karla Stein and explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory elderly adults ages 60 and above. Currently, the facility has (1) hospice resident 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, (2) bathrooms, (1) staff room, (1) staff bathroom, a living area, a dining area, a kitchen, an outside seating area and a garage. 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 105.8 degrees F. A comfortable temperature of 75 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 residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Two fire extinguishers were charged. A review of the Medication Records Administration (MAR) was observed to be maintained in order and complete. (Evaluation Report continues LIC 809-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2023

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 II	FACILITY NUMBER: 198320289
	VISIT DATE: 08/19/2023

NARRATIVE

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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 and earthquake drills were conducted on 07/14/23. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 09/17/22 through 09/17/23. The facility is current on CCL license annual dues.

An audit of residents #1-#5 (R1-R5) service files and staff #1-#6 (S1-S6) personnel files revealed to be complete. Interviews were conducted with (3) residents and (1) staff. The facility has the current administrator's certification on file for Mart H Pamintuan #6019786740 Expiration 05/23/2024.

LIC 9120 Advisory was provided.

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 Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2023

LIC809 (FAS) - (06/04)

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