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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003990
Report Date: 02/24/2023
Date Signed: 02/27/2023 01:52:22 PM


Document Has Been Signed on 02/27/2023 01:52 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
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:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Elena PinzariuTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 2/24/23 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with licensee and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 daily self-screening affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by caregiver 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 and licensee completed the infection control domain and facility was found to be in substantial compliance at this time. LPA confirmed a infection control plan is in place

LPA advised: Use of Guardian for staff clearance and roster management, that PIN 23-02 be printed and reviewed with all, review emergency/ disaster plan and PIN 22-24 collaborating with HH and Hospice.

LPA requested: resident roster, LIC 500 and copy of Liability Insurance provided. Documents to be submitted to LPA via email by 3/3/23.

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: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
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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