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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320186
Report Date: 08/20/2022
Date Signed: 08/20/2022 03:25:45 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/20/2022 03:25 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:
08/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Karla Stein TIME COMPLETED:
03:01 PM
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On 08/20/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with administrator Karla Stein and explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory or (6) ambulatory elderly residents ages 60 and above. The facility is approved for (2) hospice residents.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) residents' rooms, two (2) common bathrooms, (1) staff bathroom, a living area, a dining area, a kitchen, and an outside covered patio area.

LPA toured the physical plant. There were no obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be within Title 22 regulations and were operational. The water temperature measured 110.7 F. A comfortable temperature of 74 degrees was maintained in the facility.

LPA observed the facility to be appropriately furnished at the time of the visit. Storage areas for personal hygiene and objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has (2) fire extinguishers that are fully charged, and smoke detectors operable. A working landline telephone remains available. The last fire drill was conducted 03/30/22. The facility has a First Aid Kit fully stock and maintained in order. Administrator's certificates are current for Mart Pamintuan #601978670 and Karla Stein #6025974740.

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 08/20/2022
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INFECTION CONTROL:
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 staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of residents' vaccination along with daily temperature checks were conducted. The facility has an approved Mitigation Plan Report on file with CCLD. The facility has submitted Infection Control Plan for 2022 with CCLD.

No deficiencies were cited during this visit.

An exit interview was conducted, and a copy of this report is provided to Karla Stein.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2022
LIC809 (FAS) - (06/04)
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