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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606306
Report Date: 12/13/2022
Date Signed: 12/13/2022 02:49:59 PM

Document Has Been Signed on 12/13/2022 02:49 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: 4DATE:
12/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Samantha Alex (Administrator)TIME COMPLETED:
03:00 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) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility, LPA met with Samantha Alex (Administrator) and explained the purpose of the visit. FACILITY IS LICENSED TO SERVE 6 NON-AMBULATORY RESIDENTS AGE 60 AND ABOVE. HOSPICE WAIVER APPROVED FOR 1 RESIDENT.

The facility is located in a residential area. A tour of the single-story facility includes: 2 Living rooms, kitchen, dining area, 5 resident bedrooms, 1 staff bedroom, 4 bathrooms, 1 office, outdoor kitchen/laundry area and a detached storage room.

During today's visit, LPA observed the following: Facility shall not operate over capacity or beyond any conditions and limitation on the license. All bodies of water will be appropriately secured. Facility maintain a comfortable temperature for residents. All outdoor and indoor passageways are kept free of obstruction. Licensee ensure presence of grab bars for each toilet, bathtub and shower used by residents. Bathtub/shower have non-skid mats. Minimum of one week supply of nonperishable foods and 2 days of perishable foods was observed. Staff assisting residents with ADLs has required training. Staff responsible for direct care and supervision have current first aid training. A certified administrator is on the premise for a sufficient number of hours to manage and oversee the business operation. Medications is given per the physician’s directions. Centrally stored medicines is kept in a safe and locked place. Smoke detector and Carbon monoxide detector is operable. Fire extinguisher is fully charged. Resident #2, #3, #4's medical assessment does not contain tuberculosis test results.

Per Title 22 Regulations, the deficiencies observed are documented on LIC809D. Failure to correct the deficiencies may result in civil penalties.

An exit interview was conducted and a copy of this report and appeal rights provided to Samantha Alex.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2022
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 2
Document Has Been Signed on 12/13/2022 02:49 PM - It Cannot Be Edited


Created By: Kruz Long On 12/13/2022 at 02:31 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: 12/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)


This requirement is not met as evidenced by:Resident #2, #3, #4's medical assessment does not contain tuberculosis test results.
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2022
Plan of Correction
1
2
3
4
Licensee shall provide a medical assessment to the department for Resident #2, #3, #4 with tuberculosis test results by the POC date.
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.
SUPERVISOR'S NAME:Fernando Fierros
LICENSING EVALUATOR NAME:Kruz Long
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2