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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003990
Report Date: 10/21/2021
Date Signed: 10/21/2021 11:35:47 AM

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:GOLDEN AGE CARE HOMEFACILITY NUMBER:
347003990
ADMINISTRATOR:PINZARIU, ELENAFACILITY TYPE:
740
ADDRESS:6323 PERRIN WAYTELEPHONE:
(916) 967-3248
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH: ELENA PINZARIUTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 10/21/21 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with staff 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 was temperature screened by licensee upon entering the facility.

Administrator is present at the facility. LPA toured the interior and exterior of the facility together with licensee to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA, Administrator, and Infection control Leader completed the infection control domain and facility was found to be in substantial compliance at this time.

LPA advised: more thorough documentation of symptom screening for residents, staff and visitors; documentation is maintained for required testing; fit testing be done for proper fitting N-95s; and, LPA will arrange supply of N-95s for licensee pick-up at the RO.

LPA requested: resident roster, LIC 500, Administrator's Certificate and signature page of the LIC 610E- emergency plan. copy of Liability Insurance provided. Documents to be submitted to LPA via email by 10/28/21.

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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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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