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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001818
Report Date: 09/01/2021
Date Signed: 09/01/2021 12:30:47 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:GOLD AGE VILLAFACILITY NUMBER:
315001818
ADMINISTRATOR:OSELSKY, RAISAFACILITY TYPE:
740
ADDRESS:8100 HORSESHOE BAR ROADTELEPHONE:
(916) 652-0348
CITY:LOOMISSTATE: CAZIP CODE:
95650
CAPACITY:6CENSUS: 6DATE:
09/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Raisa OselskyTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 09/01/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator, Raisa Oselsky, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility. There are a total of five (5) residents present at the facility.

LPA toured the interior and exterior of the facility together with Administrator to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, six (6) resident bedrooms, three (3) bathrooms, kitchen, garage, staff break room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Assistant Administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
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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