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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 03:08:54 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:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:41 PM
MET WITH:Staff Samantha AlexTIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jose Villalobos conducted the case management visit to address deficiencies observed during the annual inspection. LPA met with Staff Samantha Alex and the purpose of the visit was discussed.

During the visit, LPA was not able to access staff files as they were locked in an office and no staff were able to unlock the room. LPA also observed Staff #1 (S1) to be living on site in the facility without a criminal record clearance. Facility had previously been cited for S1 not being cleared on 5/23/23.



California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 809-D.

Immediate civil penalties of $3000 shall be assessed for a maximum of 30 days as Staff #1 is still not criminally record cleared as this is a subsequent violation within a 12 month period of a civil penalty,

An exit interview was conducted and a copy of this report and appeal rights provided to Staff Samantha Alex
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
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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Document Has Been Signed on 12/21/2023 03:08 PM - It Cannot Be Edited


Created By: Jose Villalobos On 12/21/2023 at 02:32 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: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2023
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 #1 is not working or residing in the facility until Staff #1 obtained a criminal record clearance and associated to the facility and provide proof to the department by POC due date.
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Department or...: This requirement is not met as evidenced by: Staff #1 does not have a criminal record clearance or association to the facility and resides on the property, this poses an immediate health and safety risk to resident(s) in care.
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Type B
12/29/2023
Section Cited
CCR87412(a)

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87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.... This was not met as evidenced by:
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Licensee to have staff on site with access to office room when Licensee is unavailable. Licensee to make staff files available to licensing review by POC due date
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LPA was unable to access staff files as the staff files were locked in an office and no staff had a key. Licensee had the key but could not be present during visit, this poses a potential health and safety risk to residents in care.
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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:Jose Villalobos
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023


LIC809 (FAS) - (06/04)
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