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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700030
Report Date: 08/04/2022
Date Signed: 08/04/2022 01:33:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/05/2022 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20220505095147
FACILITY NAME:GOLDEN AGE LIVINGFACILITY NUMBER:
502700030
ADMINISTRATOR:RAMOS, KELSYFACILITY TYPE:
740
ADDRESS:305 CINNAMON TEAL WAYTELEPHONE:
(925) 918-3998
CITY:NEWMANSTATE: CAZIP CODE:
95360
CAPACITY:6CENSUS: 5DATE:
08/04/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Caregiver Linda GarrettTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility did not provide a refund of resident fees
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jason Lund arrived at the above facility to complete an complaint investigation. LPA Lund met with caregiver Linda Garrett and explained the reason for the visit. Caregiver Linda Garrett called Administrator Kelsy Ramos and explained the reason for the visit. Administrator Kelsy Ramos could not make the visit and gave to caregiver Linda Garrett to sign the report.
Facility did not provide a refund of resident fees- Based on LPA Lund observations, record review, and interviews, which were conducted along with a file review. according to bank records Resident (R1) paid for March fees $4500.00 on February 28, 2022 by check. R1’s death report states that R1 passed away on March 6, 2022. R1’s property was pick up on March 12, 2022 by R1’s Power of Attorney (POA). R1 admission agreement dated July 7, 2018 states that the payment would be $3500 it also states “That in the event of death, the fee for service will end upon removal of the resident’s belongs from the facility”. R1 belongs was picked on March 12, 2022 by his POA. The POA has never received an refund from the facility through March 13, 2022 through March 31, 2022.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 27-AS-20220505095147
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GOLDEN AGE LIVING
FACILITY NUMBER: 502700030
VISIT DATE: 08/04/2022
NARRATIVE
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Based on LPA observations, record review, and interviews, which were conducted along with a file review, the preponderance of evidence has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6 & Chapter number 8) is being cited on the attached LIC 9099D.An exit interview was conducted with Kelys Ramos via telephone and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20220505095147
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN AGE LIVING
FACILITY NUMBER: 502700030
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2022
Section Cited
CCR
87507(5)(c)
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Refunds required by Section 87507(g)(5)(E)3. shall be paid within 15 days of issuing the notice. The resident may request that the licensee provide a credit towards the resident’s monthly fees in lieu of the preadmission fee refund.
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The Licesnsess agrees to pay the refund of 113 per day for 19 days for a total of $2147 and $1000 for Admission agreement price. For a total of $3147 by 8/18/2022.
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R1 belongs was picked on March 12, 2022 by his POA. The POA has never received a refund from the facility through March 13, 2022 through March 31, 2022.
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/05/2022 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20220505095147

FACILITY NAME:GOLDEN AGE LIVINGFACILITY NUMBER:
502700030
ADMINISTRATOR:RAMOS, KELSYFACILITY TYPE:
740
ADDRESS:305 CINNAMON TEAL WAYTELEPHONE:
(925) 918-3998
CITY:NEWMANSTATE: CAZIP CODE:
95360
CAPACITY:6CENSUS: 5DATE:
08/04/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Caregiver Linda GarrettTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Resident's authorized representative was not provided with a copy of the Admission Agreement
INVESTIGATION FINDINGS:
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Resident's authorized representative was not provided with a copy of the Admission Agreement- Based on interviews with the Power of Attorney (POA) for Resident (R1), requested a copy of R1’s Admission agreement through a phone call with Licensee Kelsy Ramos and never received R1’s admission agreement. Licensee Kelsy Ramos never received a copy of the Power of Attorney (POA) in the mail.
Based on interviews and records reviewed, the Department (CCLD) has found the allegations to be unsubstantiated
A finding that the complaint allegation(s) are/ is UNSUBSTANTIATED means that although the allegation(s) may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.
An exit interview was conducted with Kelys Ramos via telephone and a copy of this report was left at the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4