197606306-11-19-2024-28-AS-JVIS-DB6VKZ-20241119153109

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606306
Report Date: 11/19/2024
Date Signed: 11/19/2024 03:31:17 PM

Document Has Been Signed on 11/19/2024 03:31 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	GOLDEN LEAF MANOR		FACILITY NUMBER:	197606306
ADMINISTRATOR/ DIRECTOR:	PERCY P. OLIDAN		FACILITY TYPE:	740
ADDRESS:	1140 INDIAN SUMMER AVENUE		TELEPHONE:	(626) 855-0101
CITY:	LA PUENTE	STATE: CA	ZIP CODE:	91744
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 2	DATE:	11/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Licensee Percy Olidan		TIME VISIT/ INSPECTION COMPLETED:	03:40 PM

NARRATIVE

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Licensing Program Analysts (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Licensee Percy Olidan. The following 12 (CARE) tool domains were utilized during the inspection:

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. An Infection Control Plan was observed

Physical Plant/Environment Safety:

(2) Living rooms, kitchen, dining area, (6) bedrooms of which (3) are for resident use, (4) bathrooms, (1) office, outdoor kitchen/laundry area and a detached storage room.
The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are enclosed ponds in the backyard. Cleaning supplies and toxic substances are inaccessible.
Water temperature readings measured within title 22 regulations.

Operational Requirements:

A current Plan of Operation observed. Dementia Care Plan Observed
A fire clearance for 6 residents of which (6) may be non ambulatory
Hospice care waiver approved for up to one (1) resident.
Facility does not have an active liability insurance.

Personnel Records - Staff Training:

Administrator on file is not current and administrator certificate for licensee and current administrator is currently expired.
Two (2) staff files were reviewed. Required documents observed for files reviewed.

Continued on LIC 809-C

Fernando Fierros	TELEPHONE: (323) 981- 3981
Jose Villalobos	TELEPHONE: (323) 980-4939
	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

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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Document Has Been Signed on 11/19/2024 03:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN LEAF MANOR	FACILITY NUMBER: 197606306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as there is no active liability insurance for the facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/20/2024
	Plan of Correction
1 2 3 4	Licensee to aquire liability insurance for the facility by POC due date. If unable to, Licensee to inform LPA of plan to obtain the insurance. *Note LPA observed Licensee call an insurance company and scheduled meeting to discuss rates and ability to purchase liability insurance during the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Fernando Fierros	TELEPHONE: (323) 981- 3981
Jose Villalobos	TELEPHONE: (323) 980-4939
	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/19/2024 03:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN LEAF MANOR	FACILITY NUMBER: 197606306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Personnel Records

(A) For administrators this shall include verification that he/she meets the educational requirements in Section 87405(d) through (g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as administrator certificates are expired for both staff files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/03/2024
	Plan of Correction
1 2 3 4	Staff #2 is currently completing certification renewal and will be designated as the facilities administrator by the licensee once completed. Licensee to update LPA of progress or designate another individual as the administrator by POC due date.

Section Cited

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in (1) of (2) resident files reviewed did not have a medical assessment on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/03/2024
	Plan of Correction
1 2 3 4	Facility to aquire a completed medical assessment for all residents from their physicians and provide a copy to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Fernando Fierros	TELEPHONE: (323) 981- 3981
Jose Villalobos	TELEPHONE: (323) 980-4939
	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN LEAF MANOR	FACILITY NUMBER: 197606306
	VISIT DATE: 11/19/2024

NARRATIVE

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Staffing:

Sufficient staff observed during visit

Resident Records - Incident Reports:

A total of two (2) resident files were reviewed. (1) resident is missing a medical assessment.

Resident Rights - Information

Required postings observed

Food Service:

Sanitation practices and kitchen cleanliness was observed.
Kitchen has utensils for clients to use and to store their meals

Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed.
Activities supply observed

Incident Medical and Dental:

Emergency transportation available
First Aid Kid observed
(2) of (2) Resident medications reviewed

Disaster Preparedness:

Emergency and Disaster Plan observed but is outdated.
Last Emergency Drill observed

Residents with Special Health Needs:

Needs and Services Plans are on file.
Currently (0) residents receiving hospice services.

Inspection Tool was completed and per Title 22 deficiencies are being cited on todays visit. See 809-D pages attached

Exit interview conducted. Copy of this report and appeal rights were discussed and provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC809 (FAS) - (06/04)

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