198320289-8-25-2023-11-AS-MVAO-CWXQXM-20231025123347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320289
Report Date: 08/25/2023
Date Signed: 08/25/2023 09:40:11 AM

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
07/19/2023 and conducted by Evaluator Perry Scott

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230719163702

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:	08/25/2023
		UNANNOUNCED	TIME BEGAN:	09:23 AM
MET WITH:	Karla Stein		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Resident sustained multiple falls in care.
Facility staff failed to meet residents hygiene needs.

INVESTIGATION FINDINGS:

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On 07/27/23, Licensing Program Analyst (LPA), Perry Scott initiated a 10-day complaint investigation at the facility listed above. LPA Scott met with Karla Stein, Administrator, and explained the purpose of today’s visit was to investigate the allegations listed above.

On 07/27/23, the investigation consisted of the following:

During today's visit LPA conducted interviews with the staff (S1- S2), residents were in quarantine and could not be interviewed. LPA requested and obtained copies of the following documents: Resident and staff roster, Id/Emergency Information, pre-placement appraisal, admission agreement, physicians report, and resident appraisal for resident (R1).

The investigation revealed the following: Regarding allegation #1: Resident sustained multiple falls in care.

Report continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230719163702

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: 08/25/2023

NARRATIVE

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On 07/27/23, LPA interviewed S1-S2. 2 of 2 staff denied the allegation that Resident sustained multiple falls in care. Both staff confirmed that R1 has never fallen at this facility before. This was the first time that R1 had fallen out of bed. S1 stated that R1 was placed in the bed with secure railings, that was set up with motion sensors. But somehow R1 fell out of bed. LPA verified that an incident report was sent to CCLD. R1-R5 could not be interviewed due to cognitive difficulties.

Based on interviews, and records reviewed there is insufficient evidence to support the allegation: Resident sustained multiple falls in care. 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 is Unsubstantiated.

Allegation #2: Facility staff failed to meet residents’ hygiene needs.

On 07/27/23, LPA interviewed S1-S2. 2 of 2 staff denied the allegation that Facility staff failed to meet residents’ hygiene needs. Both staff confirmed that all residents’ hygiene needs are being performed daily. S2 stated, “We make sure that the residents’ personal hygiene needs are taken care of daily. We make sure that they are bathed, dressed properly, and that when they use the restroom, they’re hands are washed and cleaned. As well as brushing their teeth”. R1-R5 could not be interviewed due to cognitive difficulties.

Based on interviews and observations, there is insufficient evidence to support the allegation: Facility staff failed to meet residents’ hygiene needs. 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 is Unsubstantiated.

No deficiencies were cited.

An exit interview was conducted, and a hard copy of this report was provided to Karla Stein, Administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC9099 (FAS) - (06/04)

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