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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700820
Report Date: 03/11/2024
Date Signed: 03/12/2024 07:46:24 AM


Document Has Been Signed on 03/12/2024 07:46 AM - 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 10FACILITY NUMBER:
502700820
ADMINISTRATOR:PLACINTAR, MARINELAFACILITY TYPE:
740
ADDRESS:3213 INVERNESS ST.TELEPHONE:
(209) 495-2504
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 5DATE:
03/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marinela Placintar TIME COMPLETED:
12:00 PM
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On 03/11/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived to this facility unannounced to conduct an Annual visit. LPA met with staff member (SM), Sandy Lamey and explained the purpose of the visit. LPA asked that SM Lamey call the Facility Designated Administrator (FDA), Marinela Placintar and inform her that CCL was present at this time. Shortly after, LPA met with FDA Placintar and explained the purpose of the visit.

Current census was 5. This facility is currently licensed to hold 6 residents who may be deemed non-ambulatory. This facility has a hospice waiver for 2 and has a dementia plan on file. Current census was 4. Administrator holds an active and current certificate #6000942740 and expires on 06/23/2024.
LPA reviewed 3 resident files and 2 staff files. All files were complete and up to date.

LPA Pascua observed a locked centralized stored medication cabinet located in the kitchen. Along with the staff member, the LPA observed, reviewed, and compared resident medication and electronic medication dispensing logs. First Aid Kit was present and contained all of the required components.
A tour with FDA Placintar was conducted. Fire extinguisher located in the hallway was serviced by Jorgensen Co on 02/27/2024.
Dining areas, living areas, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time.
Kitchen area was toured. LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supply to meet the residents needs. Knives were observed to be locked and made inaccessible to the residents in care.
A tour of the garage was conducted. Additional storage for supplies were identified. Additional food supply was identified.
A tour of the laundry room was conducted, laundry detergent, bleach and all other cleaning supplies were made inaccessible to the residents at this time.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN AGE 10
FACILITY NUMBER: 502700820
VISIT DATE: 03/11/2024
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A tour of the resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time. A tour of two staff bedrooms were also conducted.
A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees.
The exterior of the physical plant was in good repair with no hazards present. 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

No deficiencies were observed or cited during this annual visit. A copy of this report was given to Facility Designated Administrator.
Exit interview was conducted
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
LIC809 (FAS) - (06/04)
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