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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 01:43:15 PM

Document Has Been Signed on 01/15/2025 01:43 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:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Franca OfforTIME VISIT/
INSPECTION COMPLETED:
10:25 AM
NARRATIVE
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On January 15, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an incident report the Department received on January 12, 2025. LPA met with Administrator, Franca Offor, and explained the purpose of the visit.

LPA and Administrator discussed incident occurred on November 30, 2024 and report was drafted on December 3, 2024 but it was not submitted to Community Care Licensing as Administrator did not know who was the assigned analyst to submit to. Administrator stated she was informed by LPA Mknelly on December 10, 2024 that there has been a change of assigned analyst. LPA explained report should have been submitted by December 7, 2024.

LPA and Administrator discussed that all incident reports are to be submitted within a seven days as stated in 87211 Reporting Requirements. Additionally, LPA and Administrator discussed that incident reports are to be faxed to the Department and/or emailed to Sacramento North Regional Office inbox. LPA provided Administrator LPA's business card which obtains the fax number information.

As a result of today's visit, deficiencies cited. Please see LIC 809-D.

Exit interview and a copy of the report and appeal rights was 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 01:43 PM - It Cannot Be Edited


Created By: Cassie Yang On 01/15/2025 at 12:23 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2025
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... (D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by:
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Licensee is to submit a procedure of how to ensure incident reports are submitted to Community Care Licensing in a timely manner.

POC is due 1/31/2025; failure to provide POC by due date may result to $100 per day until received and/or corrected
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Based on file review and interview, Licensee did not comply as LPA Yang received the LIC 624 on January 12, 2025 when incident occurred on November 30, which poses a potential risk to residents in care.
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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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