502700162-9-16-2023-27-AS-APAA-CVQV7F-20230916161106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700162
Report Date: 09/16/2023
Date Signed: 09/16/2023 04:11:30 PM

Document Has Been Signed on 09/16/2023 04:11 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 HOME CARE VIII		FACILITY NUMBER:	502700162
ADMINISTRATOR:	KENROY ANDERSON		FACILITY TYPE:	740
ADDRESS:	3013 QUEENS GATE COURT		TELEPHONE:	(209) 495-2504
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	6	CENSUS: 6	DATE:	09/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:56 AM
MET WITH:	Kenroy Anderson		TIME COMPLETED:	12:00 PM

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On 09/16/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA was greeted by Staff Member (SM), Vanscott Smith and explained the purpose of this visit. LPA Pascua asked SM Smith go call the Facility Designated Administrator (FDA) to inform them that CCL was present at this time. Shortly after, LPA Pascua met with FDA Kenroy Anderson and explained the purpose of the visit.
This facility is licensed to serve 6 residents of which all may be non-ambulatory. This facility has a hospice waiver for 4 and a dementia plan on file.
Current census is 6. A brief interview with Kenroy Anderson was conducted.
LPA reviewed 3 resident files and 2 staff files. 1 out 3 resident files did not have a complete Pre-Appraisal form. 2 out of 3 resident files were current and up to date. 2 out of 2 staff files were current and up to date.
The Facility Designated Administrator has a current administrator certificate #6062116740 and expires on 1/2/2024.
A tour of the facility was conducted. The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been annually inspected by Jorgenson Co on 02/27/2023.
The kitchen area was toured. LPAs observed a non-perishable and perishable foods in the cabinets and refrigerator. Additional food supplies were identified in the garage. LPA observed a locked centralized stored medication cabinet located in the kitchen. Along with the administrator, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.

A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time.

A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 HOME CARE VIII	FACILITY NUMBER: 502700162
	VISIT DATE: 09/16/2023

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Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.

Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.

A tour of the garage was conducted. Additional perishable food supplies were identified.

The exterior of the physical plant was toured. Perimeter fence was observed to be stable and gates were in good repair.

A technical assistance was provided for Section 87456(a)(2).

The following forms and documents were requested to be updated and submitted into CCL

-LIC 308

-LIC 400

-LIC 500

-LIC 610

As a result of this visit, no deficiencies were observed or cited during this annual visit. An exit interview was conducted and copy of the 809 and 809-C was provided to Licensee, Marinela Placintar.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2023

LIC809 (FAS) - (06/04)

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