197606306-12-23-2025-28-AS-EMAT-DPMS8C-20251223123855

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606306
Report Date: 12/23/2025
Date Signed: 12/23/2025 12:42:28 PM

Document Has Been Signed on 12/23/2025 12:42 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 MANOR		FACILITY NUMBER:	197606306
ADMINISTRATOR/ DIRECTOR:	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: 3	DATE:	12/23/2025
TYPE OF VISIT:	POC	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:11 AM
MET WITH:	Staff in Charge - Adrianne Gray		TIME VISIT/ INSPECTION COMPLETED:	12:50 PM

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( Licensing Program Analysts (LPAs) Elena Mallett and Cynthia Chan conducted an unannounced POC visit and met with Staff in Charge, Adrianne Gray regarding citations issued on 12/11/25. The purpose of the visit was to inspect the facility to ensure the deficiencies cited on 12/11/25 were corrected and were 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. Staff 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: Per Staff Licensee stated she will handle the POCs upon return.

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.

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.

As of today's visit S2 and S3 did not have current CPR and First Aid training on file,On today's visit Staff was using unoccupied residents room. Civil Penalties issued on today's visit in the amount of $ 400 for the period of 12/20/25-12/23/25 and will be ongoing until the deficiency is corrected.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025

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: 12/23/2025

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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.

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 poses/posed a potential health, safety or personal rights risk to persons in care.

On today's visit S3 did not have a TB test in their file. Civil Penalties issued on today's visit in the amount of $400 for the period of 12/20/25-12/23/25 and will be ongoing until the deficiency is corrected.

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.

Based on interview with Licensee current Liability Insurance is available. This affects 3 out of 3 residents in care.

On today's visit Current Liability insurance has not been provided.Civil Penalties issued on today's visit in the amount of $400 for the period of 12/20/25-12/23/25 and will be ongoing until the deficiency is corrected.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025

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: 12/23/2025

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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 LPAs observed curtain rods in the living room were not properly secured to wall, the closet doors in both resident rooms did not slide back and forth properly, and there was debris in the carport.

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.

On today's visit the curtain rod was not secured to the walls, the closet doors had not been fixed and the debris in the carport was present. Civil Penalties issued on today's visit in the amount of $400 for the period of 12/20/25-12/23/25 and will be ongoing until the deficiency is corrected.

CCR 87204(a) - Limitations-Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license.

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.

On today's visit Staff was using unoccupied residents room. Civil Penalties issued on today's visit in the amount of $400 for the period of 12/20/25-12/23/25 and will be ongoing until the deficiency is corrected.

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.

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.

On today's visit, the PRN medication was not available for Resident 3. Civil Penalties issued on today's visit in the amount of $400 for the period of 12/20/25-12/23/25 and will be ongoing until the deficiency is corrected.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025

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: 12/23/2025

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CCR 87405(a)

All facilities shall have a qualified and currently certified Administrator...

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.

On today's visit there was no documentation of a qualified Administrator working for the facility. Civil Penalties issued on today's visit in the amount of $400 for the period of 12/20/25-12/23/25 and will be ongoing until the deficiency is corrected.

CCR 87305(a) - Alterations to Existing Buildings or New Facilities

(a) Prior to construction or alterations, all facilities shall obtain a building permit.

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.

On today's visit the building permits were not provided for the converted storage room and bathroom by breaksfast nook that were not on the facility sketch.Civil Penalties issued on today's visit in the amount of $400 for the period of 12/20/25-12/23/25 and will be ongoing 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. A copy of this Licensing Report will be emailed to Licensee Percy Olidan.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025

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: 12/23/2025

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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 Resident 1 (R1) file did not contain a TB test

At today's visit Resident 1's file did not contain a TB test.Civil Penalties issued on today's visit in the amount of $400 for the period of 12/20/25-12/23/25 and will be ongoing until the deficiency is corrected.

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.

On today's visit room with missing smoke detector was locked and inaccessible. Civil Penalties issued on today's visit in the amount of $400 for the period of 12/20/25-12/23/25 and will be ongoing until the deficiency is corrected.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025

LIC809 (FAS) - (06/04)

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