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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700774
Report Date: 07/15/2024
Date Signed: 07/15/2024 02:54:02 PM

Document Has Been Signed on 07/15/2024 02:54 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GOLDEN AGE SENIOR DAY CARE SERVICESFACILITY NUMBER:
392700774
ADMINISTRATOR/
DIRECTOR:		TANG, RENEEFACILITY TYPE:
775
ADDRESS:920 N YOSEMITE STTELEPHONE:
(209) 546-0715
CITY:STOCKTONSTATE: CAZIP CODE:
95203
CAPACITY: 48CENSUS: DATE:
07/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:09 PM
MET WITH:Karla Guzman, Renee TangTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
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On 7/15/2024, LPA Johnson arrived at facility to conduct a case management for an incident that took place on 6/5/2024.

The information received detailed that R1 was not getting her basic needs met as related to food service, medication administration and medical appointments.

During the course of the investigation it was discovered that R1 is living with supportive living service through a vendor of Valley Mountain Regional Center. The SLS service is monitored by the regional center and this information has been relayed to the Service Coordinator.

There has been a meeting with the IDT team and the outcomes have improved since the 6/5/2024 meeting.

LPA was made aware that R1 has not had additional incidents with SLS services since the meeting. As a result of this visit, no deficiencies were cited.

Exit interview
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2024
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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