<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320289
Report Date: 03/02/2023
Date Signed: 03/02/2023 04:05:32 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/23/2023 and conducted by Evaluator Martessa Brown
COMPLAINT CONTROL NUMBER: 11-AS-20230223150413
FACILITY NAME:GOLDEN EDEN IIFACILITY NUMBER:
198320289
ADMINISTRATOR:PAMINTUAN, MART HYSAMFACILITY TYPE:
740
ADDRESS:5849 E. WALTON STREETTELEPHONE:
(323) 441-3691
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY:6CENSUS: 5DATE:
03/02/2023
UNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:TIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Illegal Eviction
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 3/2/23, Licensing Program Analyst (LPA) Martessa Brown conducted an initial complaint visit to the above facility and investigate the above allegations. LPA conducted Covid-19 risk assessment before entering the building and no Covid-cases. LPA met with Karla Stein, the Administrator and the purpose of the visit was explained.

The investigation consisted of the following: On 3/2/23 LPA Brown toured the physical plant with the administrator. LPA Interviewed owner Mart Pamintuan, staff S2-S4, and residents R2-R3, LPA did not interview R1 due to resident had already left the facility. LPA attempted to interview R4 and other residents were unable to interview. LPA obtained and reviewed the following records LIC 500 and Resident roster, R1 emergency contact, Admission Agreement, physician report, weekly resident care schedule and eviction notice and other documentation.

The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 11-AS-20230223150413
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/02/2023
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
26
27
28
29
30
31
32
Allegation: Illegal eviction

It was alleged that the Administrator sent an e-mail stating they were evicting the resident because the Administrator did not have the "manpower" to take care of Resident #1 and the e-mail had no end date. LPA conducted an interview with the owner Mart Pamintuan, Residents #2 - #3 (R2 - R3), attempted interview with Resident #4 (R4), and no interview with Resident #1 (R1) as the resident moved out on 10/06/22. Based on residents' interviews two out of four residents stated staff were having issues with being able to change R1 due to Resident #1's weight and would need two (2) people in order to reposition the resident. During interview, Owner Pamintuan and Administrator Stein stated staff would not want to come to work. As a result, the owner e-mailed an Eviction Notice on 02/04/23 to R1’s family members. During interview, Owner Pamintuan was aware of a 30-day eviction protocol and did not include an end date and reappraisal. LPA reviewed the Eviction Notice letter that stated the facility was unable to keep R1 due to manpower; and, they will need to find another location. Based on documentation obtained there is sufficient evidence to support the above allegation of illegal eviction, therefore the allegation is substantiated.

Based on LPA observations and interviews and records review, the preponderance of evidence standard has been met; therefore, the above allegation) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview conducted, appeal rights were explained, and a copy of this report was provided to Administrator, Karla Stein.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Elizabeth Ceniceros
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20230223150413
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/09/2023
Section Cited
CCR
87224(a)(4)
1
2
3
4
5
6
7
87224 Eviction Procedures
(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required ..(4)If, after admission, it is determined that the resident has a need not previously identified and a reappraisal..
This requirement was not met as evidence by:
1
2
3
4
5
6
7
Facility will review to submit proof that they understood Title 22 section 87224(a)(4) and a plan on how they will follow eviction procedure by due date to LPA Brown.
8
9
10
11
12
13
14
Based on observation and interviews conducted, Licensee did not ensure R1 had a reappraisal perform to identify R1's needs before eviction.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3