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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701702
Report Date: 07/22/2026
Date Signed: 07/22/2026 06:53:24 PM

Document Has Been Signed on 07/22/2026 06:53 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:
502701702
ADMINISTRATOR/
DIRECTOR:		TIMOTEO, JANINEFACILITY TYPE:
740
ADDRESS:305 CINNAMON TEAL WAYTELEPHONE:
(559) 770-1508
CITY:NEWMANSTATE: CAZIP CODE:
95360
CAPACITY: 6CENSUS: 4DATE:
07/22/2026
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:10 PM
MET WITH:Carlos PascoTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to follow up with compliance on the citations from the annual. LPA met with Caregiver Carl Pasco and explained the purpose of the visit. later Christnine(administrator by phone)

Physical
kitchen locks on half doors: Locks removed.
Showers are functional: one is still disconnected. the remaining shower is accessible only through a bedroom of another resident.
Weeds in the back: dealt with excepting a patch near a side gate. there are still many garbage bags of dead weeds, that present an obstruction to the use of the side gate. and the gates themselves are only somewhat able to swing freely and latch closed, there is some rust on the latches and there is some minor dragging into the ground.
staff food labeled/dated:yes
Fire drill log: exists, last drill 5/2/26
Fire extinguishers: dated april 30th 2026.
610d: exists

Continued on c page.
Liza King
Noel Wolf Petersen
DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 LIVING NEWMAN
FACILITY NUMBER: 502701702
VISIT DATE: 07/22/2026
NARRATIVE
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Medical
med records:Review of medications: one resident: 2 medications did not make it to a residents mar, one perscribed as a daily prn, one perscribed as routine. The medication orders were availible digitally, a log of the dispersal of those drugs was not. one residents, 1 medication 600mg Ibuprophin is not present, staff provided the statement that it was being ordered, no document support for the refill call. one resident has a medication that is totally out, a colesterol med, family refuses so far to get it filled, LPA was shown text exchange where the family was warned about the need to fill it with 2 weeks and 1 week of dosages left. The LPA gave guidance, the facility has a responsibility to assist with medication as needed, and it may be time to talk to the family member about surrendering this level of control of the medication. One resident does not have medication since the 6th of june, about two weeks now, excepting her self injectables. The staff made a statement that the client, refuses to go to the pharmacy to get them refilled. LPA gave guideance that the client has the right to refuse and not participate in their medical treatment up until they have a court order saying they do not.
Medication destruction log: Log not availible, staff belives it is located in the facility somewhere and will email it to the LPA(address below)
Death reports timely: yes. last client who had died was reported and no clients have passed since.

Staff
Fingerprinting for all staff: Lic 500 has all eligble entries on gaurdian database

Clients
rail orders: no full rails, all beds have half or no rails
Needs and services plans dated appropriately to the last year: not for one client on hospice with dementia, the other clients seem to have them dated between 2023 and 2026, LPA gave guidance the dementia clients should have needs and services plans filled out annually, and other clients as needed following a change in condition.
602's dated appropritely to the last year: yes
Client inventory of safeguarded property logs: not well filled out in one case(jewelry, photoalbums) and not present at all in another case
Liability/workers compensation insurance: a copy will be emailed to the LPA(noel.wolfpetersen@dss.ca.gov).

Citations issued on following d-Page.

A copy of the report was read and given to the designated staff for signing, a copy will be emailed to the address on file. exit interview was conducted, appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2026 06:53 PM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 07/22/2026 at 05:28 PM
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 NEWMAN
FACILITY NUMBER: 502701702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/23/2026
Section Cited
CCR
87465(a)(1,2)

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 87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. (2) The licensee shall provide assistance in meeting necessary medical and dental needs.
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LPA suggested that its time to have a conversation with the family and the perscribing doc, because a families refusal does not negate the facilitys legal obligation to ensure a residents health needs are met, if an agreement cant be reached that either the family will be more responsible with delivering drugs on time
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This requirement was not met as evidenced by: record review of the MAR: one client is out of a routine drug and staff report in interview a family thats refusing to cooperate with aquiring the drug.

Not following this requirement poses a risk for the clients health, saftey, and personal rights.
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or the facility should manage the clients medications, the LPA belives matter needs to be escalated to the ombudsman or APS as a medical neglect by the family. the facility will develop a plan of action regarding this matter and inform the LPA by end of day 7/23/26.designated representitve agrees.
Type A
07/23/2026
Section Cited
CCR87303(a)

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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LPA is suggesting that matieral be immediately removed by the poc date (7/23/26) and the facility enact regular(semi annual) sweep of the emergency route gates for hazzards and obstructions. picures to the lpa(noel.wolfpetersen@dss.ca.gov) designated representitve agrees.
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This requirement was not met as evidenced by: a lot(8+) of garbage bags of flamable biological matter in the pathway of the evacuation route gate.

Not following this requirement poses a risk for the clients health, saftey, and personal rights.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2026


LIC809 (FAS) - (06/04)
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