Community Care Licensing

Document Has Been Signed on 08/11/2021 07:03 PM - It Cannot Be Edited

FACILITY NAME:	GOLDEN AGE INC.		FACILITY NUMBER:	415600471
ADMINISTRATOR:	ZITSER, ALEX		FACILITY TYPE:	740
ADDRESS:	624 CYPRESS AVENUE		TELEPHONE:	(650) 877-8258
CITY:	MILLBRAE	STATE: CA	ZIP CODE:	94030
CAPACITY: 6		CENSUS: 3	DATE:	08/11/2021
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Alex Zitser		TIME COMPLETED:	07:00 PM

SUPERVISORS NAME: Julio Montes LICENSING EVALUATOR NAME: Audrey Jeung 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

Link to Parent Document Below:

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 CCR 87355	1 2 3 4 5 6 7	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,	1 2 3 4 5 6 7	LIC9182 and photo ID for staff R.S. is given to LPA today. Deficiency corrected and cleared
	8 9 10 11 12 13 14	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.	8 9 10 11 12 13 14
Type B 08/18/2021 Section Cited CCR87211	1 2 3 4 5 6 7	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.	1 2 3 4 5 6 7	Plan of correction to be submitted to CCLD BY DUE DATE
	8 9 10 11 12 13 14	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.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Julio Montes LICENSING EVALUATOR NAME: Audrey Jeung 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