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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606306
Report Date: 12/21/2023
Date Signed: 12/21/2023 03:08:30 PM


Document Has Been Signed on 12/21/2023 03:08 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 MANORFACILITY NUMBER:
197606306
ADMINISTRATOR:PERCY P. OLIDANFACILITY TYPE:
740
ADDRESS:1140 INDIAN SUMMER AVENUETELEPHONE:
(626) 855-0101
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY:6CENSUS: 1DATE:
12/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Staff Samantha AlexTIME COMPLETED:
02:40 PM
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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 Staff Samantha Alex. The following 12 (CARE) tool domains were utilized during the inspection:

LPA was able to completed three (3) of (12) CARE tool domains such as the following:
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.


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


LPA was unable to gain access to the office. LPA was unable to gain access to staff files. LPA to return at a later to complete remaining domains. Per Title 22 Regulations, the deficiencies observed are documented on separate LIC 809.

An exit interview was conducted and a copy of this report and appeal rights provided to Staff Samantha Alex.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
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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