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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606306
Report Date: 05/23/2023
Date Signed: 05/23/2023 03:25:06 PM

Document Has Been Signed on 05/23/2023 03:25 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: 2DATE:
05/23/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Walter Posada (Resident)TIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced Case Management visit to the facility. LPA was greeted by Walter Posada (Resident) and allowed entry. The purpose of the visit is to investigation information received by the Department indicating Staff #1 is working in the facility without a criminal record clearance. LPA also observed an Individual who is not a Resident or Staff residing in a room in the covered patio area but room is not part of the facility sketch. A short time later, Staff #1 arrived at the facility. Percy Olidan (Licensee) also arrived to the facility and LPA explained the purpose of the visit. LPA interviewed Percy Olidan in the living room area. LPA informed Percy Olidan of over due annual fees of $741.
Based on record review, interview and observations, it was determined that Staff #1 and Individual residing in a non-permitted room in the covered patio area does not have a criminal record clearance. LPA also observed Individual residing in a room erected without a permit in the covered patio area was designated for Resident use. LPA request a copy of the Staff schedule to ensure there is Staff in the facility 24 hours a day to provide care and supervision to Residents but Percy stated that there is no Staff schedule. Percy Olidan states that the intentions is to close the facility within the year and move the 2 Resident to the next door facility (Indian Summer Place).

California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Immediate Civil Penalties of $500 for Staff #1 and $500 for Individual assess on LIC421BG.

Exit interview conducted with Percy Olidan and a copy of this report and appeal rights provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2023
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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Document Has Been Signed on 05/23/2023 03:25 PM - It Cannot Be Edited


Created By: Kruz Long On 05/23/2023 at 02:55 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: 05/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2023
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the
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Licensee shall ensure Staff #3 is not working for the facility until Staff #3 obtained a criminal record clearance and associated to the facility and provide proof to the department. Licensee shall also ensure Individual is not present at the facility until Individual obtained a criminal record clearance and associated to the facility and provide proof to the department.
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Department or...: This requirement is not met as evidenced by: Staff #1 does not have a criminal record clearance. Individual residing in a non-permitted room in the covered patio area does not have a criminal record clearance.
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Type B
06/06/2023
Section Cited
CCR87307(a)(1)

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87307 Personal Accommodations and Services
(a) (1) There shall be common rooms such as living rooms, dining rooms, dens or other recreation/activity rooms. They shall be of sufficient space and/or separation to promote and facilitate the program of activities and to prevent such activities from interfering with other functions.
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Licensee shall either remove the non-permitted room in the covered patio area or obtain a permit with a Fire Clearance.
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This requirement is not met as evidenced by: Individual residing in a room erected without a permit in the covered patio area was designated for Resident use.
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Kruz Long
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023


LIC809 (FAS) - (06/04)
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