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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700720
Report Date: 01/15/2025
Date Signed: 01/15/2025 02:00:13 PM

Document Has Been Signed on 01/15/2025 02:00 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GOLDEN AGE LIVINGFACILITY NUMBER:
342700720
ADMINISTRATOR/
DIRECTOR:		KITNIKONE, SUNNIE E.FACILITY TYPE:
740
ADDRESS:3375 LA CADENA WAYTELEPHONE:
(208) 866-7968
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY: 6CENSUS: 6DATE:
01/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Franca OfforTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On January 15, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection. LPA met with Administrator and explained the purpose of the visit.

Today's visit, LPA and Administrator conducted a tour of the facility. Areas toured included but not limited to: five residents bedrooms, staff room, two bathrooms, laundry room, pantry, kitchen and the common areas. LPA observed sharps and toxins being locked and secured. LPA observed fire extinguisher present with service date of June 5, 2024. LPA observed active Administrator Certificate present with expiration date of 09/27/25. LPA observed facility having 2+ days of perishable and 7+ days of non perishable foods.

LPA and Administrator discussed that since staff room has the emergency exit door for the non ambulatory rooms, staff room shall be unlocked and free of medications, sharps and toxins. If wished to store the following, it shall be properly stored to be inaccessible to residents in care. LPA and Administrator discussed that Emergency Disaster Plan is to be reviewed and updated annually by the facility. LPA and Administrator discussed quarterly fire and earthquake drills to be conducted.

File review conducted for three personnel and six residents records. LPA observed no LIC 602 for R1 prior to R1's admission. R1 is residing in an ambulatory only room. LPA and Administrator discussed that residents with dementia and/or any walking assistance such as crane, walker, wheelchair cannot reside in the ambulatory only room unless on hospice.

Deficiencies observed. Please see LIC 809-D.

Exit interview conducted and copy of report and appeal rights provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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 2
Document Has Been Signed on 01/15/2025 02:00 PM - It Cannot Be Edited


Created By: Cassie Yang On 01/15/2025 at 01:01 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN AGE LIVING
FACILITY NUMBER: 342700720

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above as LPA did not observe LIC 602A for R1 prior to R1's admission at the facility. Only LIC 602A present was from 12/28/2024 with non-ambulatory status which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Licensee is to submit a statement of compliance that Licensee shall ensure prior to admission, LIC 602 is obtained for resident to confirm residents ambulatory status are in compliance to fire clearance.

POC due 1/31/2025, failure to provide POC by due date may result to $100 per day until corrections received and/or corrected.
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.
SUPERVISOR'S NAME:Anthony Perez
LICENSING EVALUATOR NAME:Cassie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2025


LIC809 (FAS) - (06/04)
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