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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701270
Report Date: 08/28/2023
Date Signed: 08/28/2023 01:58:28 PM

Document Has Been Signed on 08/28/2023 01:58 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 LIVING NEWMANFACILITY NUMBER:
502701270
ADMINISTRATOR:GARRETT, LINDAFACILITY TYPE:
740
ADDRESS:305 CINNAMON TEAL WAYTELEPHONE:
(925) 918-3998
CITY:NEWMANSTATE: CAZIP CODE:
95360
CAPACITY: 6CENSUS: 6DATE:
08/28/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator Kelsy RamosTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a Post licensing Inspection. LPA met with care staff and later with Administrator Kelsy Ramos. LPA Lund explained the reason for the visit. Census 6.

LPA Lund and Administrator Kelsy Ramos toured/inspected facility including all common areas used by residents. LPA observed that there are four bedrooms that residents occupied, and they contained the required furnishings. Kitchen area was clean and stocked with pots, pans, and dishes. LPA observed sufficient 7- day nonperishable and 2- day perishable food supply. All cleaners, knives and other kitchen hazards are kept inaccessible to residents in care. The facility's fireplace is entirely enclosed, and the licensee will add a metal screen as additional secured space between the room and the glass enclosure. Medications will be locked in a cupboard adjacent to the kitchen. Resident files and staff files are maintained in a neat, orderly and logical manner as to ensure ease of access of information for both facility and Licensing staff. Exterior facility grounds were toured. Facility has a covered patio area for residents. Facility will be licensed for 6 Non-ambulatory including both dementia and hospice wavier for 3. Fire extinguisher are charged and smoke alarms are operating and connected to the whole house alarm system. Facility has required carbon monoxide. LPA Lund reviewed three staff & residents files.

No deficiencies observed during the visit. Exit report given.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2023
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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