198320289-7-5-2022-11-AS-AALR-CG2RKW-20220705130614

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320289
Report Date: 07/05/2022
Date Signed: 07/05/2022 01:06:39 PM

Document Has Been Signed on 07/05/2022 01:06 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	GOLDEN EDEN II		FACILITY NUMBER:	198320289
ADMINISTRATOR:	PAMINTUAN, MART HYSAM		FACILITY TYPE:	740
ADDRESS:	5849 E. WALTON STREET		TELEPHONE:	(323) 441-3691
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY: 6		CENSUS:	DATE:	07/05/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	Mart Pamintuan		TIME COMPLETED:	01:20 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 7/5/2022 Licensing Program Analyst (LPA’s) Antonia Alvizar and Stephanie Cifuentes conducted an announced visit to the facility for purpose of a pre-licensing evaluation. Today’s pre-licensing evaluation was conducted with applicant Mart Pamintuan. On 2/28/2022 an initial application was received for a Residential Care Facility for the Elderly. The requested capacity is for 6 residents facility has a fire clearance for 6 non-ambulatory residents only. Structure: Facility is a 6-resident bedroom, 3- bathrooms, 1 one-story house with a 1 car attached garage and an outdoor shaded area in the back yard. The resident bedrooms are spacious and easily accommodate the resident's furnishings. There is a shaded back patio which contains a table and 6 chairs. Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Bedrooms Residents: All six bedrooms have one bed, one chair, one nightstand, overhead lighting, closets, and dressers. All drawers comply with the requirement of 8 cubic feet of space. There was one designated staff bedroom observed. Bathrooms: All 3 bathrooms have working toilets, wash basins and shower/bathtub. There are grab rails next to both toilets and showers. The tile in bathrooms are made from noon skid material. LPA observed adequate lighting in hallway leading to bathrooms via nightlights. Continued on 809c

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN EDEN II	FACILITY NUMBER: 198320289
	VISIT DATE: 07/05/2022

NARRATIVE

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Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen; sheets, pillowcases, hand towels, bath towels and wash clothes where observed stored in bathroom cabinet and hallway closet.

Emergency Phone Numbers, Exit Plan & Menu: The telephone system has a land line which was called by LPA and is operational. Emergency Disaster Plan and "See something, Say something, Let Us Know" posted & readily available for review on the wall in front entry. Two fully charged fire extinguishers were found in the facility, one mounted in bedroom hallway and one in the living room.

Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet next to kitchen sink. Food supply was adequately stored in kitchen refrigerator and cabinets and consists of the following: A variety of fresh and canned fruit, vegetable and meat food items.

Smoke Detectors: 12 dual carbon/smoke detectors are present in the facility. All were tested and are fully operational.

Appliances: Oven, stove, microwave, dish washer, washer, and dryer working. There are 2 refrigerators, one in the kitchen and one in the garages. Refrigerator and freezer are at the correct temperature for food storage. The residence is equipped with central heat and air.

Toxins: Locked/stored in cabinet in laundry area.

Medications, First-Aid Kit & Book: Area for medication storage was inspected, they will be kept in a locked kitchen cabinet. Area for records was inspected, they will be stored in locked file cabinet present in living room. First aid kit, located in a locked cupboard in kitchen area, was inspected which has at least the following: thermometer, tweezer, scissor, antiseptic, bandages, gauze. First aid and medications are available for staff use but inaccessible to residents.

Continued on 809c

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN EDEN II	FACILITY NUMBER: 198320289
	VISIT DATE: 07/05/2022

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Residents & Staff Files: Records of staff and residents shall be stored in a file cabinet in living room, section has been inspected along with the available records present.

Reading Material, Games, Equipment & Materials: The facility has board games, puzzles, playing cards, and other recreational materials for the resident's use.

Pool/Jacuzzi & Pets: LPA's did not observe any pet or bodies of water at the facility.

Fire clearance: Fire Clearance was approved on 5/12/2022 for 6 non-ambulatory residents with no special instructions. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits.

Component III: Conducted at the Pre-Licensing visit, on 7/5/2022 at Golden Eden II, information provided about how to operate the facility within substantial compliance.
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An exit interview was conducted, and a copy of this report has been furnished to the applicant.

Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to the applicant.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022

LIC809 (FAS) - (06/04)

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