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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701270
Report Date: 07/17/2024
Date Signed: 07/25/2024 09:25:09 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/17/2024 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20240517142342
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: 5DATE:
07/17/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kelsy Ramos, LicenseeTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility did not provide adequate supervision resulting in resident being injured while in care.
INVESTIGATION FINDINGS:
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On 07/17/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility unannounced to present findings for the allegation noted above. LPA Campbell was met by Licensee Kelsy Ramos and explained the purpose of the visit.

During the investigation, LPA Campbell interviewed staff and residents, reviewed resident documents, toured the facility, identified the location where the allegation occurred and confirmed that all staff were cleared to work at the facility. Of the 5 staff working at the facility, 4 were interviewed and 3 staff stated they had not been present during the incident. Of the residents interviewed, none were able to recount if the allegation had occurred. The one staff member present during the incident was in the midst of preparing a meal when the resident was injured.

When LPA Campbell inquired about the camera’s presence in the facility, S1 stated that they no longer worked and they had not been upgraded due to the added cost. The owner had no documentation from the security company verifying this change.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20240517142342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 NEWMAN
FACILITY NUMBER: 502701270
VISIT DATE: 07/17/2024
NARRATIVE
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Based on the interviews although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to 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
LIC9099 (FAS) - (06/04)
Page: 2 of 2