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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606306
Report Date: 12/19/2025
Date Signed: 12/19/2025 12:23:54 PM

Document Has Been Signed on 12/19/2025 12:23 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:
12/19/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:09 AM
MET WITH:Staff in Charge-Adrianne GrayTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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 Elena Mallett conducted an unannounced POC visit and met with Staff in Charge, Adrianne Gray. The purpose of the visit was discussed. The purpose is regarding citations issued on 12/11/25. The visit was to inspect the facility to ensure the deficiencies cited on 12/11/25 were corrected and discussed. Staff Adrianne Gray stated Licensee Percy Olidan has gone to the Phillipines on a personal matter and has not been at the facility since 3:30 AM on 12/11/25. Adrianne Gray stated Licensee was told about deficiencies from 12/11/25 visit.
On todays visit, LPA Mallett observed the following deficiencies have not been corrected:

Section: 87303 (a) Maintenance and Operation. Due Date: 12/12/25

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. 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.

On today’s visit, LPA Mallett observed that the hallway smoke detector near the bathroom was still missing. LPA not able to check smoke detector in Staff room near breakfast nook as the room was locked and Licensee did not leave keys for Staff. Staff reported Licensee instructed staff to repair smoke detectors but staff does not have access to the locked room where one broken smoke detector is located. Staff stated they have been unable to go to the store . Staff was able to locate a spare smoke detector and the smoke detector near resident's room was fixed during visit. Deficiency was not able to be cleared today due to not all smoke detectors in facility being operable. Civil Penalties issued on today’s visit in the amount of $700.00 for the period 12/13/25 through 12/19/25 and will be on going until the deficiency is corrected.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2025
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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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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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: 12/19/2025
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Health & Safety Code: 1569.618(c)(30 (a) Other Provisions Due Date: 12/12/25

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: On 12/09/25, during staff record review, 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.

On today’s visit, LPA Mallett did not observe that First Aid and CPR trainings had been completed. Staff Adriane Gray stated Licensee stated the trainings would be arranged to be done by staff upon Licensee’s return from the Philippines. Civil Penalties issued on today’s visit in the amount of $700.00 for the period 12/13/25 through 12/19/25 and will be on going until the deficiency is corrected.

An exit interview with Staff Adrianne Gray was conducted and the failure to correct deficiencies cited per Health and Safety Code and Califronia Code of Regulations Title 22 was discussed.The Civil Penalties assessed today was discussed . A copy of Appeals Rights was provided along with a copy of this Licensing Report.

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

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
LIC809 (FAS) - (06/04)
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