Community Care Licensing

Document Has Been Signed on 12/26/2023 02:21 PM - It Cannot Be Edited

FACILITY NAME:	GOLDEN LEAF MANOR		FACILITY NUMBER:	197606306
ADMINISTRATOR:	PERCY P. OLIDAN		FACILITY TYPE:	740
ADDRESS:	1140 INDIAN SUMMER AVENUE		TELEPHONE:	(626) 855-0101
CITY:	LA PUENTE	STATE: CA	ZIP CODE:	91744
CAPACITY: 6		CENSUS: 1	DATE:	12/26/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Licensee Percy Olidan		TIME COMPLETED:	02:35 PM

SUPERVISORS NAME: Fernando Fierros LICENSING EVALUATOR NAME: Jose Villalobos LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2023

Link to Parent Document Below:

FACILITY NAME: GOLDEN LEAF MANOR	FACILITY NUMBER: 197606306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/26/2023

Type A

Section Cited

CCR

87465(a)(6)

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as several medications have not been ordered from the pharmacy and added to the centrally stored medications list for resident #1, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/27/2023
	Plan of Correction
1 2 3 4	Facility to order Resident #1's medications and provide proof to LPA by POC due date.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Fernando Fierros LICENSING EVALUATOR NAME: Jose Villalobos LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2023

Link to Parent Document Below:

FACILITY NAME: GOLDEN LEAF MANOR	FACILITY NUMBER: 197606306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/26/2023

Type B

Section Cited

HSC

1569.605

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the licensee could not provide a copy of their insurance at the time of visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Licensee to obtain a copy of their insurance and provide to LPA by POC Due date.

Type B

Section Cited

CCR

87412(a)(13)(B)1

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). 1. For Certified Administrators, a copy their current and valid Administrative Certification meets this requirement. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as Administrator certificates are expired, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Licensee to provide LPA with a current or pending Administrator Certificate or provide Proof of training (or enrollment) along with all other requirements found on CCL website for Administrator certificate renewal to LPA by POC due date.

SUPERVISOR'S NAME: Fernando Fierros LICENSING EVALUATOR NAME: Jose Villalobos LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2023

Link to Parent Document Below:

FACILITY NAME: GOLDEN LEAF MANOR	FACILITY NUMBER: 197606306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/26/2023

Type B

Section Cited

HSC

1569.626(a)

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as staff Jocelyne Serra does not have proof of trainings completed on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Licensee to provide proof of training for staff or provide plan to provide necessary training to staff by POC due date.

Type B

Section Cited

HSC

1569.695(a)

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the emergency disaster plan is not updated to the curent form for the LIC 610D which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Licensee to complete LIC 610D for the facility and provide to LPA by POC due date

SUPERVISOR'S NAME: Fernando Fierros LICENSING EVALUATOR NAME: Jose Villalobos LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2023

Link to Parent Document Below:

FACILITY NAME: GOLDEN LEAF MANOR	FACILITY NUMBER: 197606306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/26/2023

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as there is no record on file of last emergency drill completed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Licensee to conduct an emergency drill for the facility and provide proof with sign in sheet of participants by POC due date.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Fernando Fierros LICENSING EVALUATOR NAME: Jose Villalobos LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2023

FACILITY NAME: GOLDEN LEAF MANOR	FACILITY NUMBER: 197606306
	VISIT DATE: 12/26/2023