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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001187
Report Date: 03/09/2020
Date Signed: 05/26/2020 11:35:46 AM

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 AGEFACILITY NUMBER:
507001187
ADMINISTRATOR:MARINELA PLACINTARFACILITY TYPE:
740
ADDRESS:3521 EFFINGHAM LANETELEPHONE:
(209) 491-0674
CITY:MODESTOSTATE: CAZIP CODE:
95357
CAPACITY:6CENSUS: 4DATE:
03/09/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Marinela Placintar, LicenseeTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst Bruce Jacobs conducted a case management visit at the home and met with Licensee Marinela Placintar. LPA spoke to the two (S-1,2) staff working on the previous with the five residents in the home. LPA questioned staff regarding working conditions and did not receive information that the facility was not in compliance. LPA observed the required labor laws poster placed in the home. LPA observed an adequate amount of food in the home and received information that there has not been any disruption in utility services. Home and resident 4 rooms viewed

One deficiencies was issued on this visit as staff doe not have their own bedroom to sleep in.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2020
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
FACILITY NUMBER: 507001187
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2020
Section Cited

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Personal Accommodations and Services. Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility
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Based on observation the licensee did not meet this regulation by not having beds for the caregivers to sleep on in the home This does not afford them a comfortable living condition and privacy.
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2020
LIC809 (FAS) - (06/04)
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