<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700162
Report Date: 09/17/2024
Date Signed: 09/17/2024 04:23:33 PM


Document Has Been Signed on 09/17/2024 04:23 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:GOLDEN AGE HOME CARE VIIIFACILITY NUMBER:
502700162
ADMINISTRATOR:KENROY ANDERSONFACILITY TYPE:
740
ADDRESS:3013 QUEENS GATE COURTTELEPHONE:
(209) 495-2504
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 5DATE:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marinela Placintar TIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/17/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA met with Licensee, Marinela Placintar and explained the purpose of the visit. The purpose of this visit was to conduct an annual visit. There were two staff members present, Emmanuel Akinleye and Sandy Laney.
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 5. A brief interview with Licensee Placintar was conducted.
A review of 5 resident files were conducted. It was observed that all residents had a dementia diagnosis and did not updated Needs and Services plans on file. 4 out 5 residents were obtaining hospice services from various hospice agencies. A review of 3 staff files were conducted. 3 out 3 staff files were complete and up to date.
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 purchased on 08/30/2024.
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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN AGE HOME CARE VIII
FACILITY NUMBER: 502700162
VISIT DATE: 09/17/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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.

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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2