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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 06:48:28 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:POCUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Marisa Tadeo and Alex ZitserTIME COMPLETED:
06:30 PM
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LPA Jeung observed backyard, bathrooms and Covid signage in response to observations made and technical assistance provided on 7/26/21 during annual inspection.

The following observations are made:

- LPA was temperature screened upon entry and signed visitor log
- Daily symptom screening and temperature log is observed for residents ONLY
- Sign for information about facility visitation is posted at front door
- Handwashing reminder signs are posted in all but one bathroom
- Staff are wearing face coverings
- There is ONE COVID sign posted in living room--avoid close contact with those who are sick, cover cough/sneeze, avoid touching eyes, nose, mouth, clean and disinfect surfaces often, stay home if you are sick, wash hands often
-- Additional reminder signs are advised to be posted, including one for residents to report acute respiratory illness to staff
- Liquid soap is present in all bathrooms, and paper towels are available
- There is still debris in backyard that should be removed from premises
- Proof of payment to CDSS for renewal of RCFE administrator certification was submitted

Mr. Zitser will provide update to LPA on completion of building permit application for room addition and approval from city. See citation issued on 7/26/21.
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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