198320289-7-25-2024-11-AS-DLEE-D7HSK9-20240725135623

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320289
Report Date: 07/25/2024
Date Signed: 07/25/2024 01:56:44 PM

Document Has Been Signed on 07/25/2024 01:56 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	GOLDEN EDEN II		FACILITY NUMBER:	198320289
ADMINISTRATOR/ DIRECTOR:	STEIN, KARLA		FACILITY TYPE:	740
ADDRESS:	5849 E. WALTON STREET		TELEPHONE:	(323) 441-3691
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY: 6		CENSUS: 6	DATE:	07/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:23 AM
MET WITH:	Karla Stein		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

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On July 25, 2024, Licensing Program Analyst (LPA) Wendy Gibb and Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced required annual visit using the CARE Inspection Tools. LPAs met with Administrator, Karla Stein and explained the purpose of this visit. The facility is licensed for 6 non-ambulatory residents and 2 hospice approved waivers. Currently, there are six (6) residents over the age of 60.

Structure The facility is a single-story structure located in a residential neighborhood. It consists of the following: (6) residents' rooms, (2) bathrooms, (1) staff room, (1) staff bathroom, a living area, a dining area, a kitchen, an outside seating area and a garage.

Physical Plant LPAs and Administrator Karla Stein toured the facility inside and outside. LPA observed There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 110 degrees F. A comfortable temperature of 75 degrees F. was maintained in the facility.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GOLDEN EDEN II	FACILITY NUMBER: 198320289
	VISIT DATE: 07/25/2024

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Bedrooms LPA inspected all six (6) bedrooms. All bedrooms were observed to have the required furniture including beds, dressers, nightstands with lamps, chairs, and ample storage space for personal belongings. All bedrooms were observed to be clean, in good repair, and have ample lighting.

Bathrooms LPA inspected the facility bathrooms. In the resident’s bathroom the toilet, faucets, and shower were fully operational. All safety handrails were securely fastened. LPA observed the showers to be clean and free of mold or mildew. The shower had a nonskid material in bottom and shower chair. Resident’s toiletries are secured in a cabinet under the sink. The water temperature measured 110-degrees Fahrenheit. The Staff bathroom was observed to be clean. The toilet and faucets are operational. Both bathrooms were observed to be clean, in good repair and within Title 22 regulations.

Linens & Hygiene LPA observed all beds to have the required linens including mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed an ample supply of linens, towels, and blankets in the hall closets. LPA observed incontinence care products stored in the resident’s closets and in the hall closet. LPA observed an extra supply of hygiene products secured in a cabinet in the laundry room.

Kitchen/Laundry Room LPA inspected the kitchen and observed all appliances to be in good working repair, including stove/oven, microwave, dishwasher, washer, dryer, refrigerator, and additional freezer. LPA observed an ample supply of cutleries, pots, pans, and bowls to be in good repair.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GOLDEN EDEN II	FACILITY NUMBER: 198320289
	VISIT DATE: 07/25/2024

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LPA observed knives and additional sharps to be secured in locked drawers in the kitchen and are inaccessible to residents. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. All foods and condiments were labeled with the date when they were opened and date of when they expire. All food was properly stored and labeled. Cleaning products and toxins were secured in a locked cabinet above the washer and dryer and are inaccessible to residents. The water temperature measured 109-degrees Fahrenheit.

Common Rooms In the living room, LPA observed, ample seating for all residents and space to accommodate resident’s wheelchairs. In the dining room, LPA observed a rectangle table and chairs to accommodate all residents. At time of visit, LPAs observed all the residents participating a video guided exercise (chair yoga) LPA observed all walkways and hallways to be clear, clean, and free of obstructions and hazards. LPA observed ample lighting is all rooms. The facility is maintained at a comfortable temperature.

Safety LPA observed and tested smoke/carbon monoxide detectors to be fully operable. LPA observed an addition Carbon Monoxide detector in the hallway. LPA observed 2 fully charged fire extinguisher mounted on the wall, last serviced on 3/6/24. The last emergency drill was conducted on 06/06/24. LPA inspected the First Aid kit and found it contained an ample supply of required items and a manual. LPA observed the required posting in the facility. LPA observed all exits to be clear and easily accessible. There are no firearms or ammunition stored on the premises.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GOLDEN EDEN II	FACILITY NUMBER: 198320289
	VISIT DATE: 07/25/2024

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Medications LPA observed all centrally stored medications in their original packaging and are secured in a locked cabinet in the laundry room. LPA reviewed four (4) Resident’s medications and matched them to the Medication Administration Record (MARs). locked medication cabinet. 4 out of 4 Resident’s MARs and medications are consistent with properly documented records.

Files LPA reviewed four (4) resident files and found they contained all the necessary documentation. LPA reviewed four (4) staff files and found they contained the required documentation, certification, and training. LPA reviewed copies of Client Roster, Staff Roster, Emergency and Disaster Plan (LIC610E), Activity Schedule, Meal Menu, Plan of Operation, Liability Insurance, and Admission Packet with Advertising. Liability Insurance expires on 09/17/2024.

Infection Control During the visit, LPA observed the facility’s infection control practices. LPA was properly screened for Covid-19 symptoms and temperature was checked upon arrival. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log, and records of daily Covid-19 screening and temperature checks of residents and staff. PPE supplies are readily available to staff, and an additional 30-day supply of PPE was observed. Sufficient paper towels, cleaning, and disinfecting supplies were observed. All staff were wearing a face covering. LPA observed required postings throughout the facility.

LPA did not observe any deficiencies during the time of visit.

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

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

LIC809 (FAS) - (06/04)

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