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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701270
Report Date: 07/17/2024
Date Signed: 07/17/2024 04:54:23 PM

Document Has Been Signed on 07/17/2024 04:54 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 NEWMANFACILITY NUMBER:
502701270
ADMINISTRATOR/
DIRECTOR:
GARRETT, LINDAFACILITY TYPE:
740
ADDRESS:305 CINNAMON TEAL WAYTELEPHONE:
(925) 918-3998
CITY:NEWMANSTATE: CAZIP CODE:
95360
CAPACITY: 6CENSUS: 5DATE:
07/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Linda Garrett, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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On 07/17/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility unannounced to conduct an annual inspection. LPA Campbell was met by Direct Staff Person Cindy Fuentes and 10 minutes later, Administrator Kelsey Ramos arrived. Both staff were verified as being cleared to work at the facility. Upon entry, LPA Campbell observed residents using the facilities or watching TV. A nurse and spiritual counselor visited the residents during the inspection.

The Facility is located in a one story building with 6 bedrooms and three bathrooms. It is licensed to house up to 6 non-ambulatory residents with dementia and has a hospice waiver for four. Upon entry there is a common area which leads into a kitchen and a dining/TV room. The master bedroom is reserved for staff and contains an en suite bathroom. There are 5 resident bedrooms all of which are singles except for Bedroom A. Bedroom A may be shared by two residents.

LPA Campbell observed enough fresh perishables to last more than three days. The pantry non-perishables would last more than 7 days. Sharps were locked and inaccessible to residents. When measured, hot water in bathrooms were found to 108 degrees Fahrenheit as required by regulations. The thermostat was set at 76 degrees Fahrenheit and the fire extinguisher was last inspected on January 10, 2024.

LPA Campbell discussed mandatory reporting with Administrator Garrett. When LPA Campbell provided resources about mandatory reporting from the Department website, Administrator Garrett stated she would use it for in-service training.

Based on observation, the facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time. An exit interview was conducted and a copy of this report was given to the facility.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2024
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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