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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320289
Report Date: 11/15/2023
Date Signed: 11/15/2023 09:46:45 AM

Document Has Been Signed on 11/15/2023 09:46 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:GOLDEN EDEN IIFACILITY NUMBER:
198320289
ADMINISTRATOR:STEIN, KARLAFACILITY TYPE:
740
ADDRESS:5849 E. WALTON STREETTELEPHONE:
(323) 441-3691
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 6CENSUS: 6DATE:
11/15/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Karla Stein TIME COMPLETED:
09:55 AM
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On 11/15/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management visit at this facility. LPA met with administrator Karla Stein and explained the purpose of the visit was to gather information for a complaint in association with facility Sterling Senior Living 3 #198320308 complaint # 11-AS-20231109114136.

LPA interviewed the administrator and resident #1(R1) during this visit between 08:44 am am. LPA collected the following information associated with (R1):
  • ID/Emergency Information LIC 601 (dated: 11/05/23)
  • Appraisal/Needs and Services Plan LIC 625(dated: 11/07/23)
  • Physicians Report LIC 602 (dated:10/31/23)
  • Preplacement Appraisal Information LIC 603 (dated: 11/7/23)
  • Original Centrally Stored Medications LIC 622 (dated: October 2023)
  • Medication Administration Record (dated: November 2023)
  • Current Centrally Stored Medications LIC 622 (dated: November 2023)

An exit interview conducted with Karla Stein and a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
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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