Golden Leaf Manor

Type of visit: Office

An informal conference was held on 5/6/26 at the Monterey Park Adult and Senior Care Program Regional Office. Participants in the meeting were Fernando Fierros (Licensing Program Manager), Elena Mallett and Cynthia Chan (Licensing Program Analysts), and Percy Palada (Licensee/Administrator). The purpose of this conference is to discuss the issues of non-compliance for the past three years. The following regulations were discussed: · Health and Safety 1569.618 - Administration and management of residential care facilities; substituted qualifications; employee scheduling · Health and Safety 1569.311 Carbon monoxide detectors required; inspection · Health & Safety 1569.605 Liability insurance; coverage requirements · Health & Safety 1569.626 Advertising for special care, special programming, or a special environment for elderly with dementia; training requirements · Health & Safety 1569.695 Emergency Plans · 87465 Incidental Medical and Dental Care · 87755 Inspection Authority of the Licensing Agency · 87405 Administrator - Qualifications and Duties · 87506 Resident Records · 87303 Maintenance and Operation (Continue on the LIC809C) · 87307 Personal Accommodations and Services · 87411 Personnel Requirements - General · 87305 Alterations to Existing Building or New Facilities · 87204 Limitations - Capacity and Ambulatory Status · 87458 Medical Assessment · 87412 Personnel Records · 87355 Criminal Record Clearance Licensee agrees to do the following to maintain compliance with Title 22 regulations. The licensee shall submit the following to LPA by 5/15/26. · Current Liability insurance per Health and Safety Code 1569.605 · Contact City Planning regarding permits for alterations · TB test results for Staff #3 * Emergency Disaster Plan - LIC610E * Infection Control Plan * current Administrator's qualifications Licensee was offered the Technical Support Program (TSP), and voluntarily agreed to participate. The annual fees are current. An exit interview was held. A copy of this report was given to the licensee.the state’s words, verbatim · CDSS document, May 6, 2026

Type of visit: POC

( 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. 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. 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. 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. 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.the state’s words, verbatim · CDSS document, Dec 23, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Elena Mallett conducted an unannounced POC visit to clear a deficiency cited on a 12/19/25 Case Management visit. LPA Mallett was met by Staff in Charge, Adrianne Gray and the purpose of the visit was discussed. Staff in charge stated Licensee Percy Olidan has been in the Phillipines on a personal matter since 12/11/25 early in the AM. Staff will assist with visit and sign the Licensing report. CCR 87465(h)(5) (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. Based on observation, the licensee did not comply with the section cited above in 3 out of 3 residents medication supply. The medication for 3 out of 3 residents was prepared in advanced and stored in pillboxes rather than in the original containers. A plan on training staff for not utilizing pillboxes to dispense medication was not received by Licensing. The pills were observed to be in the pillboxes during today's visit. 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 was conducted with Staff Adrianne Gray and the failure to correct the deficiency cited per Title 22 Regulations was discussed. The Civil Penalties assessed today were discussed. A copy of Appeal Rights was provided along with this Licensing Report. A copy of this Licensing Report will be emailed to Licensee Percy Olidan.the state’s words, verbatim · CDSS document, Dec 23, 2025

Type of visit: POC

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 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.the state’s words, verbatim · CDSS document, Dec 19, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Elena Mallett and LPA Cynthia Chan conducted an unannounced Case Management visit and met with Staff Adrianne Gray. Per Staff Gray, Licensee Percy Olidan is in the Phillipines on a personal matter. The purpose of today's visit was discussed. During the 12/11/25 Annual Continuation visit LPA did not include observations in a deficiency statement for a citation issued. The deficiency will be cited today detailing LPA's observations in the deficiency statement. LPA Mallett observed centrally stored medication for all 3 residents. However, the pills had been prepared in advance and stored in a container other than the original container.See 809-D During the visit today LPA could not review residents' file due to files being in a locked office to which staff did not have a key to access the staff office. All staff rooms were locked as well. Deficiencies per California Code of Regulations Title 22 was cited today. An exit interview was conducted and copy of this Licensing Report along with Appeal Rights were provided to Staff Adrianne Gray.the state’s words, verbatim · CDSS document, Dec 19, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h) · Plan of correction due date: Dec 20, 2025

CCR 87465(h)The following requirements shall apply to medications which are centrally stored:(5)Each resident's medication shall be stored in its origally recieved container.No medications shall be transferred between containers. This above requirement was not met as evidenced by Based on observation, 3 out of 3 residents, Residents #1-#3, medication was pre prepared and stored in pillboxes to be dispensed outside of their original container.the state’s words, verbatim · CDSS document, Dec 19, 2025

Plan of correction: By POC due date Licensee will email LPA Mallett a written plan on how staff will be trained to administer medication from the orginal conatiner and not in a pillbox.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Cynthia Chan and Elena Mallett conducted a case management visit for a health and safety check. LPAs arrived unannounced and met with staff, Adrianne Gray. The purpose of the visit was explained. Per staff, licensee Percy Olidan is in the Philippines on a personal matter. The licensee did not inform LPA of the absence and the designation of facility responsibility. Licensee's administrator's certificate has not been renewed, and there is no coverage by a designated substitute who shall have qualifications adequate to manage the facility. LPA conducted a walk through of the facility. Food supplies appear sufficient for the census. LPA could not review residents’ file due to files being in a locked office to which staff did not have a key to access the room. The other 2 staff rooms were locked and could not gain access to check on smoke detectors. Deficiencies are being cited today. An exit interview was held. A copy of this report and appeal rights were given to staff A. Gray and emailed to the licensee.the state’s words, verbatim · CDSS document, Dec 19, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87755(a) · Plan of correction due date: Jan 5, 2026

87755 Inspection Authority of the Licensing Agency (a) Any duly authorized officer, employee or agent of the licensing agency ...enter and inspect the entire premise of any place providing services at any time... This requirement is not met as evidenced by: Based on observation, LPA did not have access to the staff office and 2 staff rooms, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 19, 2025

Plan of correction: Licensee shall review regulation code 87755 and ensure that all rooms on the facility sketch are granted access to authorized agencies. The statement acknowledging this regulation has been understood shall be submitted to LPA by 1/5/26.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Jan 5, 2026

87405 Administrator - Qualifications and Duties (a) All facilities shall have qualified and currently certified administrator. When the administrator is not in the facility, there shall be coverage by a designated substitute... This requirement is not met as evidenced by: Based on interview and record review, there is no qualified administrator for this facility and there is no designated substitute in place while the administrator is not in the facility which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 19, 2025

Plan of correction: Licensee shall renew the administrator's certificate or secure a qualified administrator to manage the facility. In addition, Licensee shall submit the LIC308 Designation of Facility Responsibility form to LPA by 1/5/26.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(d) · Plan of correction due date: Jan 5, 2026

87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. This requirement is not met as evidenced by: Based on observation, the staff office was locked and staff did not have the key to access files which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 19, 2025

Plan of correction: Licensee shall ensure resident files are accessible for review by licensing. A statement/plan to ensure that licensing has access to files shall be submitted to LPA by 1/5/26.

Type of visit: Case Management - Annual Continuation

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 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 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 .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.the state’s words, verbatim · CDSS document, Dec 11, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Elena Mallett and Cynthia Chan conducted the required annual inspection. LPA arrived unannounced and met with Licensee Percy Olidan and explained the purpose of the visit. License Program Manager(LPM) Fernando Fierros joined the visit shortly after. The facility is licensed to serve 6 Residents ages 60 and above, with a hospice waiver for (1) one. Currently 3 ambulatory residents live at the facility and none are receiving hospice care. The facility is a single-story home located in a residential area in La Puente, Ca. A tour of the facility includes: 3 resident bedrooms, 3 staff rooms, 4 bathrooms, the one in the rear does not appear on the facility sketch. There is a kitchen, dining area, living room, staff office, front yard and back yard. There is an outdoor kitchen and a covered patio and a detached storage room. LPA observed storage room partially converted into a staff room that did not appear on facility sketch. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and the initial visit and observed the following: Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan. LPA observed the facility not to have current Liability insurance. A complete First Aid kit and manual was observed. See continuation page LIC 809-C Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. Required furnishings were present. Items were observed obstructing the front outdoor passageways on both sides of the house. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products and extra linen are available for residents. The hot water temperature was tested in residents' bathroom and was measured to be 122.5 F which was over the Title 22 limit. Smoke detectors were missing in the hallway, bedroom #3, two staff bedrooms and converted storage room bedroom. The carbon monoxide detectors are operable and in compliance. There was a fire extinguisher observed and it was fully charged. Infection Control: Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility. Due to time constraints, LPA will return another day to continue the Annual Inspection and issue deficiencies. An exit interview was conducted with Licensee and a copy of this Licensing Report was provided.the state’s words, verbatim · CDSS document, Dec 9, 2025

Allegation investigated: Licensee does not have sufficient funds to maintain facility operating costs. Licensee did not report the sale of property.

Licensing Program Analysts (LPAs) Cynthia Chan and Elena Mallett conducted a complaint investigation regarding the allegations above. LPAs arrived unannounced and met with the licensee/administrator, Percy Olidan. The purpose of the visit was explained. LPAs obtained copies of the utility bill, bank statements, and interviewed the licensee. Allegation - Licensee does not have sufficient funds to maintain facility operating costs. Per the licensee, she has sufficient funds to pay for all the bills. She stated she has been paying all her utility bills timely and any plumbing bills in the past. LPA obtained copies of the licensee’s bank statements and a current utility bill. The food supplies are sufficient for the 2 residents residing at the home. Based on records reviewed, the licensee has sufficient funds to pay the operating costs of the facility. The utility bills, such as electricity, gas, and water, have been paid. Unsubstantiated Allegation - Licensee did not report the sale of property. Per the licensee, the house was put up for sale about a year ago. At this time, the property has not been sold nor in escrow. The licensee stated she has informed the residents that she will be selling the property. She has also verbally reported to licensing of the intent to sell the property. Licensee is aware that she needs to inform licensing when she obtains a buyer. LPA reviewed some house listing websites, and the house is on the market but has not been sold. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with the licensee. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Oct 3, 2025 · control 28-AS-20250926145715

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Licensee Percy Olidan. The following 12 (CARE) tool domains were utilized during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. An Infection Control Plan was observed Physical Plant/Environment Safety: (2) Living rooms, kitchen, dining area, (6) bedrooms of which (3) are for resident use, (4) bathrooms, (1) office, outdoor kitchen/laundry area and a detached storage room. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are enclosed ponds in the backyard. Cleaning supplies and toxic substances are inaccessible. Water temperature readings measured within title 22 regulations. Operational Requirements: A current Plan of Operation observed. Dementia Care Plan Observed A fire clearance for 6 residents of which (6) may be non ambulatory Hospice care waiver approved for up to one (1) resident. Facility does not have an active liability insurance. Personnel Records - Staff Training: Administrator on file is not current and administrator certificate for licensee and current administrator is currently expired. Two (2) staff files were reviewed. Required documents observed for files reviewed. Continued on LIC 809-C Staffing: Sufficient staff observed during visit Resident Records - Incident Reports: A total of two (2) resident files were reviewed. (1) resident is missing a medical assessment. Resident Rights - Information Required postings observed Food Service: Sanitation practices and kitchen cleanliness was observed. Kitchen has utensils for clients to use and to store their meals Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Activities supply observed Incident Medical and Dental: Emergency transportation available First Aid Kid observed (2) of (2) Resident medications reviewed Disaster Preparedness: Emergency and Disaster Plan observed but is outdated. Last Emergency Drill observed Residents with Special Health Needs: Needs and Services Plans are on file. Currently (0) residents receiving hospice services. Inspection Tool was completed and per Title 22 deficiencies are being cited on todays visit. See 809-D pages attached Exit interview conducted. Copy of this report and appeal rights were discussed and provided.the state’s words, verbatim · CDSS document, Nov 19, 2024

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPA) Jose Villalobos conducted an Case Management - Annual Continuation using the full Care Compliance and Regulatory Enforcement (CARE) Tools to complete the yearly annual for the facility. LPA met with Licensee Percy Olidan and the purpose of the visit was discussed. The following is the remaining (9) of (12) (CARE) tool domains completed during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. An Infection Control Plan was observed Operational Requirements: A current Plan of Operation observed. Dementia Care Plan Observed A fire clearance for 6 residents of which (6) may be non ambulatory Hospice care waiver approved for up to one (1) resident. Personnel Records - Staff Training: Administrator on file is not current and is currently expired. Staff have criminal background clearances. Four (4) staff files were reviewed. Staff #1 Requires training Staffing: Sufficient staff observed during visit Resident Records - Incident Reports: A total of one (1) resident file were reviewed. Continued on LIC 809-C Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Activities supply observed Incident Medical and Dental: Emergency transportation available First Aid Kid observed (1) of (1) Resident medications reviewed Disaster Preparedness: Emergency and Disaster Plan observed but is outdated. Last Emergency Drill conducted longer than 3 months ago Residents with Special Health Needs: Needs and Services Plans are on file. Currently (0) residents receiving hospice services. Inspection Tool was completed and per Title 22 deficiencies are being cited on todays visit. See 809-D pages attached Exit interview conducted. Copy of this report and appeal rights were discussed and provided.the state’s words, verbatim · CDSS document, Dec 26, 2023

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Staff Samantha Alex. The following 12 (CARE) tool domains were utilized during the inspection: LPA was able to completed three (3) of (12) CARE tool domains such as the following: Physical Plant/Environment Safety: (2) Living rooms, kitchen, dining area, (6) bedrooms of which (3) are for resident use, (4) bathrooms, (1) office, outdoor kitchen/laundry area and a detached storage room. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are enclosed ponds in the backyard. Cleaning supplies and toxic substances are inaccessible. Water temperature readings measured within title 22 regulations. Resident Rights - Information Required postings observed Food Service: Sanitation practices and kitchen cleanliness was observed. Kitchen has utensils for clients to use and to store their meals LPA was unable to gain access to the office. LPA was unable to gain access to staff files. LPA to return at a later to complete remaining domains. Per Title 22 Regulations, the deficiencies observed are documented on separate LIC 809. An exit interview was conducted and a copy of this report and appeal rights provided to Staff Samantha Alex.the state’s words, verbatim · CDSS document, Dec 21, 2023

Type of visit: Case Management - Deficiencies

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 Alexthe state’s words, verbatim · CDSS document, Dec 21, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Dec 22, 2023

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 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.the state’s words, verbatim · CDSS document, Dec 21, 2023

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a) · Plan of correction due date: Dec 29, 2023

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: 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.the state’s words, verbatim · CDSS document, Dec 21, 2023

Plan of correction: 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