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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600471
Report Date: 08/11/2021
Date Signed: 08/11/2021 07:03:37 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: 3DATE:
08/11/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Alex ZitserTIME COMPLETED:
07:00 PM
NARRATIVE
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In response to information provided to LPA Jeung during annual inspection on 7/26/21 and observation today, deficiencies of the California Code of Regulations, Title 22, are issued on a following page.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
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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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: 08/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2021
Section Cited

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CRIMINAL RECORD CLEARANCE
A licensee may request a transfer of a criminal record clearance from one state licensed facility to another by providing the following documents to the Dept:
A signed LIC 9182 & a copy of the individual's valid photo ID issued by the U.S. government. This requirement was not met,
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as staff R.S. is present & providing care to clients, but does not have criminal record clearance & association to facility. Licensee failed to ensure that criminal record clearance & association are maintained for staff who provide care to clients, which poses an immediate health & safety risk to clients in care. LIC421 issued to assess $100 civil penalty.
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Type B
08/18/2021
Section Cited

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REPORTING REQUIREMENTS
Licensee shall furnish to CCLD reports, including written report within 7 days of the occurrence of an epidemic outbreak, which threatens the welfare, safety or health of residents, personnel or visitors. Report shall be made within 24 hours either by telephone or fax to CCLD & to the local health officer when appropriate.
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Report shall include the resident's name, age, sex, date of admission; date & nature of event; attending physician's name, findings, & treatment, if any; & disposition of the case. This requirement was not met, as 4 clients with Covid infection were not reported to CCLD in January 2021, which posed an immediate health & safety risk.
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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: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2021
LIC809 (FAS) - (06/04)
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