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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320186
Report Date: 05/20/2024
Date Signed: 05/21/2024 09:59:50 AM

Document Has Been Signed on 05/21/2024 09:59 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:GOLDEN EDEN IIIFACILITY NUMBER:
198320186
ADMINISTRATOR/
DIRECTOR:
STEIN, KARLAFACILITY TYPE:
740
ADDRESS:2602 OSTROM AVENUETELEPHONE:
(323) 441-3691
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 6CENSUS: 5DATE:
05/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:29 AM
MET WITH:Administrator Karla SteinTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 05/20/24, Licensing Program Analyst (LPA) Lizeth Villegas 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. The facility is approved for (2) hospice resident.Current census is 5, there are currently no hospice residents in care, facility fees are current, liability insurance active with expiration date of 06/26/24.

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. Resident bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to residents. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to residents, no weapons nor bodies of water on the premises, land line observed, exits and walkways are free of debris/hazards. Auditory alarms observed to be operational.

LPA conducted a records review of 2 staff records, 2 resident records, and 2 medication administration records, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 05/17/24, 2 fire extinguisher fully charged, carbon monoxide and smoke detectors are operational.

Exit interview conducted with Karla Stein, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2024
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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