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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001187
Report Date: 11/10/2020
Date Signed: 11/12/2020 10:05:21 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: 6DATE:
11/10/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Jerome Burke TIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Avelina Martinez arrived at this facility unannounced on 11/10/20 at 2:20 PM to conduct a case management visit. LPA met with Jerome Burke and explained the purpose of the visit.

LPA Martinez toured the facility with Jerome Burke. LPA Martinez conducted staff interviews for a case management.

Exit interview conducted with Jerrome Burke Due to Covid-19 precautionary measures, LPA Martinez emailed Marinela Placintar a copy of this report. An electronic email read receipt confirms receiving this report.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020
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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