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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606306
Report Date: 12/22/2021
Date Signed: 12/23/2021 11:53:54 AM

Document Has Been Signed on 12/23/2021 11:53 AM - 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: 3DATE:
12/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Percy Oldian TIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Wong conducted an annual required visit. LPA met with the administrator/licensee Percy Oldian and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed the food supply, and reviewed resident and staff files. Facility has submitted a mitigation plan and was approved 07/22/2021.

The facility is located at a residential neighborhood. The facility consists of three(3) residents rooms, two (2) live in staff bedrooms, two (2) residents bathrooms and two (2) live in staff bathrooms, living room, dining area, kitchen, mini library, patio and a detached garage. Resident Room#1 and #2 has two beds, two night stand, two drawers and sufficient closet space and lighting. Currently Resident Room #3 is used as storage due to the facility only has 3 residents. The two residents bathrooms were toured. Bathroom has required grab bars and non-skid mats. The hot water temperature tested between two residents bathrooms was 106.3 and 108.3 degrees F which is within the Title 22 regulation. While LPA inspected the resident bathroom#1 and observed there were many ants in the bathroom. The food in the kitchen and the patio has sufficient food for two days perishable and seven days non-perishable. All the appliances are clean and working properly. The common area such as living room and dining area are clean and have the required furniture. The front and back yard are maintained well.

LPA reviewed 3 resident files to confirm emergency contact is updated. LPA also reviewed staff files to confirm health screenings and fingerprint clearances. Resident #1 (R1's) Divalproex Sodium 500mg was not stored in the original container and it was stored in another pill box.

The deficiencies cited are documented on the attached 809D. A copy of the report and appeal rights will be provided to the administrator.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2021
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
Document Has Been Signed on 12/23/2021 11:53 AM - It Cannot Be Edited


Created By: Christine Wong On 12/22/2021 at 02:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 12/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance adn Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, LPA observed the bathroom#1 has a lot of ants around the sink area and toilet bowl and the floor which imposed an potenital risk of the residents in care.
POC Due Date: 01/05/2022
Plan of Correction
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The administrator will ensure the facility shall be clean, safe, sanitary and in good repair at all times. The administrator will send the plan to LPA how to prevents ants crawling around the bathroom#1 area by POC due date. --- Before LPA left, the bathroom#1 has already been cleaned, there's no more ants inside
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Christine Yee
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2021


LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 12/23/2021 11:53 AM - It Cannot Be Edited


Created By: Christine Wong On 12/22/2021 at 02:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 12/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
87465 Incident Medical and Dental Care (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and record review, LPA observed R1's medication for Divalprpex Sodium is in a different container and not the original container.
POC Due Date: 12/23/2021
Plan of Correction
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The administrator will ensure each resident medication shall be stored in its originally received container. The administrator will retrained the staff about medication and send the training log to LPA by POC due date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Christine Yee
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2021


LIC809 (FAS) - (06/04)
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