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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603803
Report Date: 09/12/2025
Date Signed: 09/12/2025 01:44:31 PM

Document Has Been Signed on 09/12/2025 01:44 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ONE GOLDEN LANDFACILITY NUMBER:
198603803
ADMINISTRATOR/
DIRECTOR:		SHIEH, IZELLAHFACILITY TYPE:
740
ADDRESS:15745 AGOSTA DRTELEPHONE:
(626) 560-9010
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 6CENSUS: 0DATE:
09/12/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Izellah Shieh, applicant/licenseeTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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
Licensing Program Analyst (LPA) Cynthia Chan conducted an announced visit to the facility for a pre-licensing evaluation.
An application was submitted to CCLD on 8/13/24 for an initial license for a Residential Care Facility for the Elderly to serve the Elderly, ages 60 years and older. The fire clearance is approved for six (6) non-ambulatory residents ages 60 and over. The applicant has submitted a request for a hospice waiver to the Centralized Applications Bureau (CAB).

LPA used the Compliance and Regulatory Enforcement (CARE) tools to conduct the inspection.
Infection Control: The licensee has an Infection Control Plan and a lead staff designated to conduct training. Facility has sufficient PPE supplies.
Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. The licensee will secure the liability insurance at $1,000,000 per occurrence and $3,000,000 total aggregate upon licensure.
Structure/Physical Plant:
The facility is a single-story home with 4 resident bedrooms (bedrooms #1 and #3 are private, and #2 and #4 are shared), 2 bathrooms, a living room, dining room, kitchen, family room, and attached garage. The bathrooms have non-skid mats in the shower area and grab bars. The facility has interconnected smoke detectors and carbon monoxide detectors throughout the home. The fireplace has a secured fence and will not be in use. Knives and sharp objects are locked in the kitchen cabinets. Cleaning solutions are locked and stored in the garage. The backyard has a covered patio with a table and chairs. The facility has auditory devices located on each exit door. There is no swimming pool on the premises. Surveillance cameras are observed in the common areas.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ONE GOLDEN LAND
FACILITY NUMBER: 198603803
VISIT DATE: 09/12/2025
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
Food Service:
There is a sufficient food supply of at least a week of non-perishable food maintained at the facility. The licensee will purchase the 2-day perishable items before admitting a resident. The kitchen is kept clean and sanitary. All the appliances are in working order. A sufficient amount of tableware, dishes, and utensils is observed. The refrigerator is maintained at 40 degrees F or below, and the freezer at 0 degrees F or below.
Staff and Residents files:
Staff and Residents' files will be maintained at the facility.

Resident Rights/Information: Resident rights, Resident councils, and complaint posters are posted in a prominent area.

Planned Activities: The facility has sufficient space to accommodate indoor and outdoor activities.

Incidental Medical and Dental: Medications will be centrally stored in the kitchen cabinet. The first aid kit contains all the required supplies along with the current first aid manual.

Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.

Residents with Special Health Needs: The facility accepts and retains residents with dementia.
The facility landline is (626) 638-3428.
Component III was conducted during the visit today.

The physical plant is cleared, and no correction is needed. However, the applicant will submit the following to the CAB for review:
· Surveillance cameras in the facility - update plan of operation
· Hospice Waiver
An exit interview was held, and a copy of this report was given to the applicant.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3