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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600471
Report Date: 07/21/2025
Date Signed: 07/21/2025 01:55:05 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/21/2025 01:55 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:GOLDEN AGE INC.FACILITY NUMBER:
415600471
ADMINISTRATOR/
DIRECTOR:		ZITSER, ALEXFACILITY TYPE:
740
ADDRESS:624 CYPRESS AVENUETELEPHONE:
(650) 877-8258
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY: 6CENSUS: 6DATE:
07/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator - Alex ZitserTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 07/21/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with caregiver Lee Collano initially, then licensee Alex Zitser arrived with administrator Marat Zitser. LPA explained the purpose of today's visit. Currently there are 6 residents in the facility and 2 staff at time of arrival.

This is a split level facility approved all residents to be non-amblatory and 2 hospice residents. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. Cameras are present through out the facility in the common areas only, and outside observing the perimeter areas of the facility. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked in the kitchen in a drawer adjacent to the facility stove. Medications are observed to be locked in a cabinet adjacent to the refrigerator. Perishable and non-perishable food items are observed as low. During the visit the son of the administrator arrived to pick up the shopping list. There are additional refrigerator and freezer in the garage area which also carry additional food supplies which is also observed as low. First aid kit is observed as complete with required items. LPA observed that there are multiple fire extinguishers in place inspected 04/25/2019 but it is charged within the normal operating range. LPA observed 3 extinguishers. Smoke detectors, carbon monoxide detectors are observed in place through out the facility, facility is equipped with full fire sprinklers through out, and central heating/cooling system. Facility is also equipped with fire alarm pull station near the front door. PPE and additional food supplies are observed as in place. Laundry area is also observed as fully operational in the garage area. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill is not documented nor conducted for at least a year which poses an immediate health and safety risk for residents in care. Water temperature was measured at 115F in a common resident bathroom in the hallway connecting to resident rooms on the lower level.

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NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: GOLDEN AGE INC.
FACILITY NUMBER: 415600471
VISIT DATE: 07/21/2025
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LPA observed rooms numerous resident rooms and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place in linen closet on the upper level. Cleaning supplies such as comet and fabuloso, are observed in the upper floor bathroom below the sink, this poses an immediate health and safety risk to residents. During today's visit LPA reviewed 6 resident files and 4 staff files. Per licensee Alexander Zitser, his son Marat Zitser is the administrator of the facility. His administrator certificate is observed as expiring 02/18/2027. Last disaster drill conducted in May 2025 .

The following updated forms are requested to be submitted to CCLD by 07/28/2025:

• Copy of updated Administrator Certificate
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or current lease

Citations are issued on this day on the attached LIC809D pages. LIC9102TV are also issued on the attached pages.

Report is reviewed with the licensee Alex Zitser and a copy is provided on this day.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/21/2025 01:55 PM - It Cannot Be Edited


Created By: Jaime Vado On 07/21/2025 at 10:53 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GOLDEN AGE INC.
FACILITY NUMBER: 415600471

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2025
Section Cited
CCR
87309(a)

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87309 Storage Space - (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This regulation has not been met as evidenced by:
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Facility shall develop a written plan showing how it will meet this regulation at all times. Written plan shall be submitted by the due date shown.
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Based on facilty observations, LPA observed cleaning solutions stored below resident bathroom sink, on the upper level. This poses an immediate health and safety risk to residents in care.
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FACILITY REMOVED ITEMS DURING TODAY'S VIST THUS THE DEFICIENCY IS CLARED ON THIS DAY.
Type A
07/22/2025
Section Cited
CCR87465(h)(2)

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87465 Incidental Medical and Dental Care (h)(2) - The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This regulation has not been met as evidenced by:


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Facility is developing a plan to ensure the medications are secured and locked within the refrigerator. The facility will secure with a lockable bag or similar that will be placed in the refrigerator.
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Based on facilty observations, LPA observed prescribed medications such as insulin and eye drops in an unlocked refrigerator of the facility in the main kitchen. This poses an immediate health and safety risk to residents in care.
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Plan and evidence of locked medications in refrigerator is to be received by due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2025


LIC809 (FAS) - (06/04)
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