One Golden Land

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tao conducted an unannounced annual visit at the facility. LPA met with the Licensee, Izellah Shieh. The reason for the visit was explained. The facility is a Residential Care for Elderly (RCFE) to serve six (6) non – ambulatory residents, ages from 60 years old and above. The facility has approved six (6) hospice waivers. Annual fees are current. The facility is a single family house which consists of four (4) resident bedrooms (bedrooms #1 and #3 are private, and #2 and #4 are shared), two (2) bathrooms, a kitchen, dining room, office area in the garage, living room, shaded patio, and attached garage. The following were reviewed during this visit: Infection Control: Sufficient PPE supplies and an Infection Control Plan maintained at the facility were observed and in compliance. Physical Plant & Environment Safety: Physical plant tour was conducted. The passageways, backyard and outdoors were free of hazards. Residents’ bedrooms were checked and in compliance. Storage areas for cleaning solutions, toxins, knives, and hazardous items were kept in a locked cabinet and were inaccessible to residents. Water temperature was tested and the temperatures were between 108.5 to 112.1 degrees F., which was in compliance with regulations. Smoke detectors and carbon monoxide detectors were operable. Fire extinguishers were observed and fully charged. (-Continued on the LIC809-C) Operational Requirements and Disaster Preparedness: Facility has an activity area furnished for outdoor use. Fire drills were conducted quarterly. Staffing and Personnel Records- Training: Sufficient staffing was observed in the facility. Staff files were reviewed and in compliance. Resident Rights-Information and resident Records-Incident Reports: Facility provided telephone landline and internet for the residents. Resident rights posters and reporting posters were displayed within the facility. Food Service: Two (2) days of perishables and one-week (7) days of non-perishables food supply were observed. The kitchen was observed to be clean. Health Related Service: Medication was properly labeled, centrally stored, and in their original containers. Incidental Medical & Dental and Emergency Intervention: Staff designated to administer medication have the proper training on file. Exit: No deficiencies were noted during this visit per California Code of Regulations, Title 22, Division 6. Exit interview was conducted with Licensee, Izellah Shieh. Copies of LIC 809s were provided.the state’s words, verbatim · CDSS document, Sep 24, 2026

Type of visit: Prelicensing

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. 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.the state’s words, verbatim · CDSS document, Sep 12, 2025

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): N/A COMP II Participants: licensee/administrator IZELLAH SHIEH Interview Method: Telephone interview On 8/5/2025, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Aug 5, 2025