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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003990
Report Date: 02/11/2022
Date Signed: 02/11/2022 04:41:11 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: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: 3DATE:
02/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Elena PinzariuTIME COMPLETED:
04:45 PM
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On 2/11/2022, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct an annual Inspection utilizing the infection control domain. LPA met with Administrator, Elena Pinzariu, and explained the purpose of the visit. Prior to initiating the 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 completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. Additionally, LPA was screened by Administrator upon entering the facility.

LPA toured the interior of the facility together with Administrator to ensure health and safety of residents in care. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA observed (2) residents in the common area and (1) resident in her room. LPA observed the Administrator Certificate to be up to date. LPA observed the fire extinguisher to be last serviced on 3/15/2021. Administrator informed LPA that she placed old ones into her car already to get serviced soon. LPA advised Administrator to have trash bin with a lid in the restroom. LPA referenced the infection control domain and confirmed testing, vaccination and exception status and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of today's inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022
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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