198320289-8-16-2023-11-AS-MVAO-CW3TVA-20230927150338

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320289
Report Date: 08/16/2023
Date Signed: 08/16/2023 01:13:16 PM

Unsubstantiated

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 Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230223150413

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: 5	DATE:	08/16/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Administrator Karla Stein		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff are not changing residents diaper timely.
Staff live in garage.
Staff took away resident's call pendant.
Administrator did not do a proper rent increase.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Administrator (A1: Karla Stein). LPA/RA conducted a risk assessment prior to entering facility. A1 informed LPA/RA that the facility has no COVID cases nor do the residents or staff have symptoms. The purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegations.

An initial 10-Day visit was conducted by LPA Martessa Brown on 03/02/23 who was met by Administrator (A1: Karla Stein). During today’s visit, LPA/RA Elizabeth Ceniceros re-interviewed Staff #4 (S4: Caregiver – A.M) and Resident #6 (R6: Room #1). LPA/RA interviewed Witness #1 (W1: former R5’s Responsible Person) via landline and Witness #2 (W2: new Resident #5’s (R5) Responsible Person). (Former) Resident #1 was not interviewed during the initial 10-Day visit by LPA as the resident had already moved out of the facility on 10/06/22. LPA/RA did not interview Resident #4 (R4) during this visit as the resident was currently in the hospital.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Elizabeth Ceniceros
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

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 4

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: 08/16/2023

NARRATIVE

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LPA/RA toured the facility’s physical plant which included the garage (photos). LPA/RA reviewed the following documents: Staff & Residents rosters, Admission Agreement, Physician’s Report, and Weekly Resident Care Schedule (from 01/23/23 to 02/26/23) for (former) Resident #1.

Regarding Allegation #2: this investigation revealed a review of (former) Resident #1’s “Weekly Resident Care Schedule” (from 01/23/23 to 02/26/23) an observation of frequent diaper changes were documented (between 12:00 a.m. – 6:00 a.m., 6:00 a.m. – 9:00 a.m., 9:00 a.m. – 12:00 Noon, 12:00 Noon – 3:00 p.m., 3:00 p.m. – 6:00 p.m., and 6:00 p.m. to 12:00 a.m.) Monday thru Friday for (former) Resident #1. Interviews conducted of facility staff corroborated that they had not received complaints from the residents and/or their responsible person/family member that staff were not changing their loved one’s diapers in a timely manner. Interviews conducted of two (2) residents corroborated that they did not have an issue with facility staff changing their diapers in a timely manner. Interviews conducted of Witness #1 and Witness #2 corroborated that they did not have concerns with facility staff not changing their loved one’s diapers in a timely manner as the witnesses would frequently visit their loved ones and not observe them to have a soiled diaper.

Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Staff are not changing residents’ diaper timely is found to be UNSUBSTANTIATED.

Regarding Allegation #3: this investigation revealed that LPA Martessa Brown conducted a a tour of the facility’s physical plant during the initial 10-Day visit. LPA/RA Elizabeth Ceniceros conducted a physical tour of the facility’s garage during the subsequent visit (photos). The garage is set up with a table and four (4) chairs, refrigerator, microwave, and a sofa for staffing lounge and break room. Interviews conducted of facility staff corroborated that they use the garage as a break room or employee’s lounge. Administrator indicated that the facility has an extra room for a “live-in” caregiver(s) that is currently occupied by Staff #5 (Caregiver) who works as the NOC caregiver for the facility. Interviews conducted of two (2) residents corroborated that they were not aware of facility staff living in the garage. Interviews conducted of Witness #1 and Witness #2 corroborated that they never saw or were aware of facility staff living in the facility’s garage. A review of the facility’s floor plan documents that the extra room is identified as a “caregiver room”. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Elizabeth Ceniceros
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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: 08/16/2023

NARRATIVE

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allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of OTHER: Staff live in garage is found to be UNSUBSTANTIATED.

Regarding Allegation #4: this investigation revealed based on LPA Martessa Brown’s observation during the 10-Day visit and LPA/RA Elizabeth Ceniceros’ subsequent visit, residents were observed to be wearing their call pendants or have it on their person. Interviews conducted of facility staff corroborated that they have never observed a staff member take away a resident’s call pendant nor received a complaint from a resident and/or their responsible person/family member that the residents’ call pendant was taken away. Interviews conducted of two (2) residents corroborated that they have not had their call pendants removed by a staff member nor observed facility staff take away a resident’s call pendant. Interviews conducted of Witness #1 and Witness #2 corroborated that they did not have issues or observe a staff member take away their loved ones or other resident’s call pendant.

Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Staff took away resident’s call pendant is found to be UNSUBSTANTIATED.

Regarding Allegation #5: this investigation revealed that (former) Resident #1 was in Room #1 (with a bathroom) when the resident moved into the facility on 06/22/2022. Resident #1 was diaper dependent and did not utilize their bathroom. Administrator stated that the resident’s rent was going to be increased and in order to keep the resident’s rent at the same cost (without increasing), (former) Resident #1 would be moved to Room #6 (without a bathroom); and, it would be the equal amount of what they were paying for Room #1 (with a bathroom). Administrator offered an option to (former) Resident #1’s Responsible Person to save them money - when the increase of rent came around - to move the resident into Room #6 (without a bathroom); and, they would still pay the same amount of rent. The resident did move into Room #6 prior to moving out of the facility on 10/06/22. A review of the (former) Resident #1’s “Admission Agreement” (dated 10/06/22) documented the “Rate for Basic Services” monthly fee for room and basic services was in the amount of Six-thousand Dollars ($6,000) and there was no amended “Admission Agreement” for a rate increase of basic services.

Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Elizabeth Ceniceros
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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: 08/16/2023

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	have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of ADMISSION AGREEMENT: Administrator did not do a proper rent increase is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report was provided to Administrator (Karla Stein).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Elizabeth Ceniceros
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4