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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320186
Report Date: 07/03/2023
Date Signed: 07/03/2023 02:58:34 PM

Document Has Been Signed on 07/03/2023 02:58 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:
3234413691
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 6CENSUS: 5DATE:
07/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:27 PM
MET WITH:Karla Stein, AdministratorTIME COMPLETED:
03:13 PM
NARRATIVE
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On 07/03/23 Licensing Program Analyst (LPA) Mario Leon arrived at the above mentioned facility to conduct a case management visit regarding the lack of continuous liability insurance at the facility. The lack of liability insurance spanned from the dates of 06/20/23 through 06/25/23. The liability insurance has been renewed on 06/26/23 which will remain valid through 06/26/24.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2023
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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Document Has Been Signed on 07/03/2023 02:58 PM - It Cannot Be Edited


Created By: Mario Leon On 07/03/2023 at 01:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN EDEN III
FACILITY NUMBER: 198320186

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/03/2023
Section Cited
HSC
1569.605

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On and after July 1, 2015, all residential care facilities for the elderly...shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000)
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The licensee has failed to have continuous coverage for this facility from 06/20/23 through 06/25/23. However, the coverage has been renewed as of 06/26/23.
The licensee has agreed to continue to remain protected under liability insurance moving hence forward.
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 in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2023


LIC809 (FAS) - (06/04)
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