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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700030
Report Date: 08/13/2021
Date Signed: 08/13/2021 02:02:31 PM

Document Has Been Signed on 08/13/2021 02:02 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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: 6DATE:
08/13/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator Kelsy RamosTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jason Lund and Licensing Program Manager (LPM) Stephenie Doub made an unannounced Case Management visit. LPA/LPM met with caregiver Autumn Rodriguez and notified Administrator (AD) Kelsey Ramos of the visit who arrived at 12:45 PM.

LPA/LPM entered the facility and did a brief tour of the interior of the facility. During the tour, LPA Lund observed a video surveillance device showing the bedroom of Resident 1 (R1) with R1 in the bedroom. Caregiver explained that the resident was a fall risk. Per R1 Medical Assessment, R1 also has sundowning and wandering behaviors. R1’s facility file, showed R1’s last medical assessment and needs and services plans had not been updated within the past 12 months.

The following deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with AD Ramos and a copy of this report along with appeal rights was provided.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2021
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 2
Document Has Been Signed on 08/13/2021 02:02 PM - It Cannot Be Edited


Created By: Jason Lund On 08/13/2021 at 12:10 PM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN AGE LIVING
FACILITY NUMBER: 502700030

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/14/2021
Section Cited
CCR
87705(c)(5)

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(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
This requirement is not met as evidenced by:
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Administrator will contact the POA to make appointment for R1
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R1’s facility file, showed R1’s last medical assessment and needs and services plans had not been updated within the past 12 months. The licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
08/14/2021
Section Cited
CCR87468.2(a)(1)

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(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.
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Administrator will remove the video surveilance.
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This requirement is not met as evidenced by: LPA Lund observed a video surveillance device showing the bedroom of Resident 1 (R1) with R1 in the bedroom. Caregiver explained that the resident was a fall risk. The licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
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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 Doub
LICENSING EVALUATOR NAME:Jason Lund
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2021


LIC809 (FAS) - (06/04)
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