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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600471
Report Date: 07/26/2021
Date Signed: 07/26/2021 06:46:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:GOLDEN AGE INC.FACILITY NUMBER:
415600471
ADMINISTRATOR:ZITSER, ALEXFACILITY TYPE:
740
ADDRESS:624 CYPRESS AVENUETELEPHONE:
(650) 877-8258
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY:6CENSUS: 2DATE:
07/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Lee Collano and Alex ZitserTIME COMPLETED:
07:00 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds of this split level home, consisting of 4 client bedrooms and a staff bedroom on the main level, plus 1 common bathroom and 2 private bathrooms. On the upper level, there are 2 client bedrooms and a common bathroom. On the lower level, there is a 1 car garage, an office and a staff room. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 2 residents present, and 2 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Alex Zitser is a certified RCFE administrator (x 6/21) that oversees facility operations.

The following updated forms/information are requested to be submitted to CCLD BY 8/9/21:

• LIC 308 Designation of Administrative Responsibility
• LIC 309 Administrative Organization
• LIC 500 Personnel Report
• Current lease agreement
• LIC 610E Emergency Disaster Plan (revised 9 pages)
• Current liability insurance
• In-service training requirements for staff
• RCFE Medication training requirements for staff

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on a following page.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GOLDEN AGE INC.
FACILITY NUMBER: 415600471
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(a)(d)(6)
PERSONAL ACCOMMODATIONS AND SERVICES
All outdoor and indoor passageways and stairways shall be kept free of obstruction.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation during facility tour, the licensee did not comply with the section cited above, as wood gate on side of house is padlocked from street side, which poses an immediate health, safety or personal rights risk to persons in care. This is one of two exits to street from backyard.
POC Due Date: 07/26/2021
Plan of Correction
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Padlock was removed in LPA's presence. Deficiency corrected and cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GOLDEN AGE INC.
FACILITY NUMBER: 415600471
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a0
ALTERATIONS TO EXISTING BUILDINGS
Prior to construction or alterations, all facilities shall obtain a building permit.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, during facilty tour, the licensee did not comply with the section cited above, as there is an additional bedroom, bathroom, elevator and hallway, which do not appear on facility sketch of 2010 and were added after initial licensure. Per administrator, he has not obtained building permits or city planning approval.
This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2021
Plan of Correction
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Plan of correction to be submitted to CCLD BY DUE DATE, which shall include specific information on persons or agencies contacted, dates contacted, and expected time of response, inspection, or approval.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3