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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701269
Report Date: 10/24/2024
Date Signed: 10/24/2024 02:04:19 PM

Document Has Been Signed on 10/24/2024 02:04 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 LIVING TURLOCK 1FACILITY NUMBER:
502701269
ADMINISTRATOR/
DIRECTOR:		RAMOS, KELSYFACILITY TYPE:
740
ADDRESS:1259 JOETT DRIVETELEPHONE:
(209) 226-0269
CITY:TURLOCKSTATE: CAZIP CODE:
95380
CAPACITY: 6CENSUS: 6DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Alicia Contreras, House ManagerTIME VISIT/
INSPECTION COMPLETED:
02:00 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 10/24/24, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced at the facility and met with Alicia Contreras, House Manager. LPA Campbell stated the purpose of the visit to conduct an annual inspection. The facility is a one story building licensed to serve 6 residents. The census is currently 6. The facility sketch matches the facility floor plan found during the visit. There are four bedrooms and two bathrooms. The Administrator is Kelsy Ramos.and their Administrator Certificate number is 6053310740 and it expires on 9/8/2025. The facility displays a See Something Say Something sign on the facility notice board.

Upon entry, LPA Campbell observed a television that was playing and a resident sitting in the living room watching. All doors and window curtains were open. LPA Campbell inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. The facility was observed to be free of odor and in good repair.

In the kitchen, LPA Campbell found enough perishable foods to last the residents two days and enough non-perishable foods to last one week. The refrigerator temperature was at 30 degrees Fahrenheit and the freezer was 0 degrees Fahrenheit. The facility thermostat is set at 75 which is within the required range of 68 and 85 degrees. The fire extinguisher was last inspected May 21, 2024 and the smoke alarm was tested successfully during the visit. Water was measured in the bathroom at 111 degrees Fahrenheit within the required range of 105 and 120 degrees.

.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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 3
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 LIVING TURLOCK 1
FACILITY NUMBER: 502701269
VISIT DATE: 10/24/2024
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
Sharps are kept locked in the kitchen and cleaning supplies are kept in the laundry room. LPA Campbell observed that the door to the cleaning supplies was not kept locked and the mechanism to lock it was on the inside of the facility and accessible to residents. The doorknob will therefore need to changed so that staff need a key to get to the laundry room and cleaning supplies. The facility made the change to the doorknob during the inspection visit.

Based on today's inspection, per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed or cited and noted on LIC 809D. Note that failure to correct any deficiencies will result in additional civil  penalties.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/24/2024 02:04 PM - It Cannot Be Edited


Created By: Renee Campbell On 10/24/2024 at 11:42 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN AGE LIVING TURLOCK 1
FACILITY NUMBER: 502701269

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705(f)(2) Care of Persons with Dementia. The following items shall be made inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, LPA Campbell observed three cleaning products that were accessible to residents in care. In addition to the aforementioned, LPA observed the laundry room which houses chemicals to be unlocked and accessible to the residents in care. The licensee did not comply with the section cited above during the inspection visit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
1
2
3
4
The licensee changed the knob during the visit so that the door to the laundry room can be locked with a key from inside the facility. In-service training will be conducted on the risks associated with the population served with said items negligently being left accessible to the residents. A signed roster as proof of training will be sent to renee.campbell@dss.ca.gov no later than Friday 10/31/24.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Lisa Rios
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3