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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600471
Report Date: 07/23/2024
Date Signed: 07/23/2024 11:48:53 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/23/2024 11:48 AM - 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:ZITSER, ALEXFACILITY TYPE:
740
ADDRESS:624 CYPRESS AVENUETELEPHONE:
(650) 877-8258
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY:6CENSUS: 5DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator/Licensee - Alex ZitserTIME COMPLETED:
11:55 AM
NARRATIVE
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On 07/23/2024, Licensing Program Analyst (LPA) Jaime Vado and Kiran Jain conducted an unannounced annual inspection visit. LPA met with caregiver Lee Collano initially, then around 0915 the administrator/licensee Alex Zitser arrived, and LPA explained the purpose of today's visit.

LPAs was allowed entry into the facility. 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. 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 in place. There are additional refrigerator and freezer in the garage area which also carry additional food supplies. First aid kit is observed as complete with required items. LPA observed that there are multiple fire extinguishers in place inspected 08/25/2019 but it is charged within the normal operating range, 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 133F in a common resident bathroom in the hallway connecting to resident rooms on the upper floor. This temperature poses an immediate health and safety risk to residents in care. Also observed in place in common areas are video cameras for resident safety.

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SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
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 4


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: 07/23/2024
NARRATIVE
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LPAs 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 are observed in the upper floor bathroom below the sink, this poses an immediate health and safety risk to residents. Facility does not handle resident monies.

During today's visit LPAs reviewed three resident files and 3 staff files. Per file reviews, staff files were not current with first aid cards or CPR cards. This poses an immediate health and safety risk to residents in care.

The following updated forms are requested to be submitted to CCLD by 07/30/2024:

• Copy of updated Administrator Certificates
• 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. Report is reviewed with the licensee/administrator Alex Zitser and a copy is provided on this day.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/23/2024 11:48 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/24/2024
Section Cited
CCR
87303(e)(2)

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87303(e)(2) Maintenance and Operation (e)(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This regulation has not been met as evidenced by:
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Facility shall develop a written plan on how to address this regulation and keep a record showing that the water temperature delivered is within regulatory standards at all times.
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Based on physical plant tour and water temperature taken in common hallway bathroom, the water temperature was measured at 133F which poses an immediate health and safety risk to residents in care.
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Type A
07/24/2024
Section Cited
HSC1569.695(c)

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§1569.695 Emergency Plans(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is notrequired during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This health and safety code has not been met as evidenced by:
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Facility shall create a written plan on how to meet this health and safety code section at all times and maintaining the record of such drills accurately and conduct drills quarterly.
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Based on documentation reviewed, LPA observed that there is no disaster drill log present. Per interviews with staff, a disaster drill has not been conducted in about a year. This poses an immediate health and safety risk to residents and staff in the facility.
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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: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 07/23/2024 11:48 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/24/2024
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, LPAs observed cleaning solutions stored below resident bathroom sinks, on both the upper level and lower 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
07/24/2024
Section Cited
HSC1569.618(c)(3)

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1569.618(c)(3) Administration and management of residential care facilities; substituted qualifications; employee scheduling - (c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This health and safety code has not been met by:
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Facility shall develop a plan in writing to reflect the assurance that all staff will have at least first aid training and one staff with CPR training and obtain curren first aid/CPR certifications to meet this requirement. Such evidence shall be submitted to the department.
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Based on staff file review observations, LPAs discovered that no staff on duty have first aid or cpr training on file. Per interview with administrator/licensee, he was unaware that the facility had to maintain first aid/cpr any longer.
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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: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4