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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606306
Report Date: 12/11/2025
Date Signed: 12/12/2025 05:38:21 PM

Document Has Been Signed on 12/12/2025 05:38 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GOLDEN LEAF MANORFACILITY NUMBER:
197606306
ADMINISTRATOR/
DIRECTOR:		PERCY P. OLIDANFACILITY TYPE:
740
ADDRESS:1140 INDIAN SUMMER AVENUETELEPHONE:
(626) 855-0101
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 6CENSUS: 3DATE:
12/11/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Staff in Charge -Adrianne GrayTIME VISIT/
INSPECTION COMPLETED:
06:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elena Mallett arrived at the facility to conduct an Annual Continuation Visit. The initial Annual visit was on 12/09/25. LPA Mallett met with Staff in Charge/ Caregiver Adrianne Gray. LPA Mallett arrived at the facility at 8 AM. The door bell was rung several times and the door knocked on and LPA Mallett verbally announced Licensing was at the door. Two phone numbers on LIS were called twice and messages left. At 8:40 AM LPA Mallett gained entry into the facility when residents were seen leaving the facility to board the Day Program Bus.Licensing Program Manager (LPM) Fernando Fierros joined the visit shortly after. LPA Mallett was informed by Staff in charge that Licensee Percy Olidan was not present at facility due to a personal matter. Staff in Charge was not able to make contact with Licensee despite several attempts. As staff in charge, Adrianne Gray agreed to sign for the report and be present for the visit.

The majority of CARE tool domains had been surveyed and documented in the Licensing Report for the initial Annual visit on 12/09/25. Deficiencies that were found then will be cited today.

The facility was toured today, 12/11/25 and risks to health and safety of residents were assessed. There was sufficient staffing to meet the needs of resident in care but Staff in Charge did not have a current CPR in personnel file. Toward the end of the day Staff in Charge showed a current CPR training on phone. A print out will be added to file at later date. Smoke detectors throughout the facility ( in non-occupied resident room, living room, hallway,staff rooms) were observed to be missing or inoperable. See 809-D.

On 12/09/25 visit the following was observed:

Continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2025
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 13
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 12/12/2025 05:38 PM - It Cannot Be Edited


Created By: Elena Mallett On 12/11/2025 at 11:28 AM
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: 12/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation], the licensee did not comply with the section cited above as carbon monoxide detector was not observed to be operable and sercured which poses an immediate health, safety or personal rights risk 3 out of 3 persons in care.
POC Due Date: 12/12/2025
Plan of Correction
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Licensee will have a secure and operable carbon monoxide detector present in the facility. Proof will be provided to Licensing via Fax by POC Due Date. POC cleared during visit today.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview with licensee and staff, the licensee did not comply with the section cited above in that medication were left accessiable to 3 out of 3 resident which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2025
Plan of Correction
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Licensee will provide proof to Licensing via fax that make all medication is inaccessiable to residents in care by POC due date. POC was cleared during visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 12/12/2025 05:38 PM - It Cannot Be Edited


Created By: Elena Mallett On 12/11/2025 at 11:28 AM
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: 12/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (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 observation, the licensee did not comply with the section cited above in 3 out of 3 residents medication supply. This affects 3 out of 3 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2025
Plan of Correction
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Licensee will provide a statement to Licensing via Fax that they understand and will comply with CCR 87465 (h)(5)
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.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2025 05:38 PM - It Cannot Be Edited


Created By: Elena Mallett On 12/11/2025 at 11:53 AM
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: 12/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)
Incidental Medical Care... For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by: On 12/09/25, it was observed that resident #1 (R1) did not have a written order on file for medication Melatonin 5 MG.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in1 out of 3 residents, R1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
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Liicensee will obtain a written order from the R1's physician and send a copy to Licensing via Fax by POC due date.
Type B
Section Cited
CCR
87411(f)
Personnel Requirements -General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician.

This requirement is not met as evidenced by: On 12/09/25 LPA observed that Staff 3 (S3) facility file did not contain a TB test.
Deficient Practice Statement
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Based on a record review, the licensee did not comply with the section cited above in 1 out of 3 staff , S3, did not have a TB test in their file which which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
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Licensee will obtain a TB test performed by a physician for S3 and provide a copy of the TB test results to Licensing via Fax by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2025 05:38 PM - It Cannot Be Edited


Created By: Elena Mallett On 12/11/2025 at 12:32 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: 12/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions 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: On 12/09/25 LPA observed Licensee's Liability Insurance did not meet the requirements of 1 million per occurence and 3 million in aggregate.
Deficient Practice Statement
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Based on a record review, the licensee did not comply as LPA observed Licensee's Liablilty Insurance to not meet the required amount which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
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Licensee to submit proof of Liability Insurance with the required amounts to Licensing via Fax by POC due date.
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit

This requirement is not met as evidenced by: On 12/09/25 LPAs observed the backyard storage shed was seperated by a wall and converted into a bedroom used by Licensee's realtive and Staff room by breakfast nook adjacent to outdoor patio contained a full bathroom . Licensee was unable to a provide a permit from the city for alterations to the facility.
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited and this affected 3 out 3 residents in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
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Licensee to submit permits from the City for the alterations to the facility( storage shed and staff room) to Licensing via Fax by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
Page: 6 of 13
Document Has Been Signed on 12/12/2025 05:38 PM - It Cannot Be Edited


Created By: Elena Mallett On 12/11/2025 at 01:06 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: 12/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services (2) The premises shall be maintained in a state of
good repair and shall provide a safe and healthful environment

This requirement is not met as evidenced by: On 12/09/25 LPAs observed curtain rod in the living room was not properly secured to wall, the closet doors in both occupied resident rooms did not slide back forth properly and there was debris in the car port ( desk and furniture)
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above and this affected 3 out of 3 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
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Licensee to remove debris from the carport area, secure curtain rod to wall and ensure closet doors in occupied residents' room are fully functional send proof of correction to Licensing via Fax by POC due date.
Type B
Section Cited
CCR
87204(a)
Limitations-Capacity and Ambulatory Staus (a) A licensee shall not operate a facility beyond the conditions and limitations specificed on the license.

This requirement is not met as evidenced by: On 12/09/25 per LPAs interviews with Licensee and Staff 3 (S3) reported that S3 sleeps in an unoccupied Resident room on an intermittant basis.
Deficient Practice Statement
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Based on interview and observation the licensee did not comply with the section cited above in 1 out of 3 residents rooms were not used by residents but by S3. This affects 3 out 3 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2025
Plan of Correction
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Licensee to send a statement to Licensing indicating that Licensee has read Section 87204 (a) Limitations-Capacity and Ambulatory Staus and will comply with this section by POC due date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2025 05:38 PM - It Cannot Be Edited


Created By: Elena Mallett On 12/11/2025 at 01:32 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: 12/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by: During a staff record review on 12/09/25 LPAs observed only one staff member had current CPR training. And that staff with CPR training does not work in the facility 24 hours a day, 7 days a week. No staff files contained a current First Aid training. On 12/11/25 LPA observed there were no staff working in the facility who had current CPR and First Aid training.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above has 2 out 3 Staff , Staff 2 and 3, did not have a current CPR training on file and 3 out 3 Staff ( S1, S2 and S3) did not have current First Aid training on file. This affects 3 out of 3 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2025
Plan of Correction
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Licensee will provide proof of current CPR training for S2 and S3 and first aid training for S1, S2 and S3 to Licensing via Fax by POC due date.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by: On 12/09/25 LPAs observed water temperture in residents' common bathroom measured at 123.4 F. On 12/11/25 LPA observed hot water in residents' common bathroom to be measured at 113.9 F.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 resident bathrooms this affects 3 out of 3 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2025
Plan of Correction
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On 12/09/25 Licensee lowered the hot water temperture. On 12/11/25 LPA observed hot water temperture within Title 22 regulations. POC cleared on 12/11/25 visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2025 05:38 PM - It Cannot Be Edited


Created By: Elena Mallett On 12/11/2025 at 02:35 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: 12/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)
All facilities shall have a qualified and currently certified Administrator...

This requirement is not met as evidenced by: On 12/09/25 LPAs observed Licensee could not provide documentation that there was a qualified and certified administrator working at the facility.
Deficient Practice Statement
1
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Based on observation, interview and record review], the licensee did not comply with section above as there was no documentation of a qualified and certified administrator this affects 3 out of 3 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
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Licensee to provide documents to licensing via Fax showing that a qualified and certifed administrator is working at the facility by POC due date.
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment (c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional' diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by: On 12/09/25 visit Resdient 1 (R1) file did not contain a TB test.
Deficient Practice Statement
1
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3
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Based on record review, the licensee did not comply with the section cited above in 1 out of 3 resident files (R1) did not contain a TB test which poses/posed a potential health, safety or personal rights risk to 3 out 3 persons in care.
POC Due Date: 12/19/2025
Plan of Correction
1
2
3
4
Licensee will provide a copy of a physician administrated TB test for R1 to Licensing via Fax by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
Page: 9 of 13
Document Has Been Signed on 12/12/2025 05:38 PM - It Cannot Be Edited


Created By: Elena Mallett On 12/11/2025 at 03:24 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: 12/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by: On 12/09/25 and 12/11/25 2 patio tables and 3 patio chairs were observed to be obstructing the outdoor passageway on the side of the patio on the left side of the facility.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the left side of the house passageway was not free of obstruction which poses an immediate health, safety or personal rights risk to persons in care. This affects 3 out 3 residents in care and poses an immediate health and safety risk to residents in care.
POC Due Date: 12/12/2025
Plan of Correction
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Staff removed obstructions during 12/11/25 visit from outdoor passageway.
POC cleared during 12/11/25 visit.
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by: On 12/11/25 it was observed that the smoke detectors throughout the facility (living room, hallway, one resident room and staff room) were either missing or non operational.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2025
Plan of Correction
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Licensee will ensure all smoke detectors throughout the facility are installed and operational. Licensee to send proof of correction to Licensing via fax to POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN LEAF MANOR
FACILITY NUMBER: 197606306
VISIT DATE: 12/11/2025
NARRATIVE
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Physical Plant & Environment Safety Continuation: On 12/09/25 LPA toured the facility and deficiencies observed are being issued today . Area along the side of the building was obstructed by patio furniture. Area in carport was obstructed by a desk and furniture. The curtain rod in the living room was not properly secured. Closet doors in both resident bedrooms were not functioning properly and needed repair. See 809-D LPA measured water temperature in resident bathroom to be 122.5 F. This is outside Title 22 regulations. See 809-D LPA observed the outdoor detached storage room was partially sectioned off to create an additional staff room. This was not on facility sketch. Another bathroom not on the facility sketch was observed by the breakfast nook.Licensee did not provide permits from the city for alterations. See 809-D Per interview with Licensee and Caregiver an unoccupied resident room on the facility sketch was being used intermittent ly by staff as a bedroom. See 809-D Carbon monoxide detector was inoperable and not permantely secured. See 809-D

Staffing: There is staffing to cover all shifts.

Resident Records-Incident Reports: LPA reviewed 4 resident files and medication logs. Resident 3 (R3)’s file did not contain a TB test. See 809-D

Personnel Records-Training: 3 staff records were reviewed. All staff had criminal background clearances. Only one staff file contained current CPR training. No current First Aid training was observed in any of the staff records. See 809-D. Licensee was the Administrator but certificate was not renewed. See 809-D . Staff 3 ‘s file did not contain a TB test. See 809-D.

Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman.

Planned Activities: Residents attend a Day program. Licensee advised to offer planned activities in the home in addition to this.

Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishable.

See 809-C

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN LEAF MANOR
FACILITY NUMBER: 197606306
VISIT DATE: 12/11/2025
NARRATIVE
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Incidental Medical & Dental: LPA observed the following during 12/09/25 visit: Medication is stored centrally in a locked staff room however, LPA observed several medications outside the medication room on a table near the glass cabinet near the living room that was accessible to residents. See 809-D. Medication is properly labeled and in their original containers. LPA observed and Licensee confirmed that two days of medications were prepared in advance and stored in pillboxes for dispensing. See 809-D During medication review LPA observed medication Melatonin for Resident #1 (R1) for which there was no current physician’s order. See 809-D

Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites.

Residents with Special Health Needs: There are no bedridden or residents using hospice or home health services at this time.

Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Liability Insurance in the requisite amounts of 1 million per and 3 million aggregate was not provided. See 809-D

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GOLDEN LEAF MANOR
FACILITY NUMBER: 197606306
VISIT DATE: 12/11/2025
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.LPA Mallett attempted to contact Licensee to verbally convey the content of this report but was only able to leave a voice message.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were deficiencies observed during the visit. An exit interview was conducted with Staff in Charge and a copy of this licensing report along with appeal rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC809 (FAS) - (06/04)
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