507001187-7-15-2025-27-AS-ELIM-DJM2C5-20250715171611

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507001187
Report Date: 07/15/2025
Date Signed: 07/15/2025 05:16:24 PM

Document Has Been Signed on 07/15/2025 05:16 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		FACILITY NUMBER:	507001187
ADMINISTRATOR/ DIRECTOR:	ELENA TRITEAN		FACILITY TYPE:	740
ADDRESS:	3521 EFFINGHAM LANE		TELEPHONE:	(209) 491-0674
CITY:	MODESTO	STATE: CA	ZIP CODE:	95357
CAPACITY: 6		CENSUS: 6	DATE:	07/15/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	Venice Andrews		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 1:30 PM on 07/15/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility `unannounced to conduct a required annual inspection and was greeted by a Caregiver. The LPA identified herself, explained the purpose of the visit, and asked to meet with the Designated Facility Administrator (DFA). A second Caregiver called the Licensee to announce the LPA’s arrival. Venice Andrews, an Administrator for Golden Age facilities, arrived at the facility at 2:00 PM and a brief interview followed. The Administrator accompanied the LPA on a tour of the physical plant. The LIcensee arrived at 4:30 PM. The CARE inspection tool was used during this inspection. This facility was a four-bedroom house located in a residential neighborhood. It was licensed to serve six non-ambulatory residents and had a hospice waiver for six residents. The census was six residents and give residents receive hospice care. There were two Caregivers on duty at the time of this visit. The LPA toured the inside of the house, including four resident bedrooms, the kitchen/dining combination room, the two bathrooms, a family room, and the garage. The entire house was clean, odor-free, and pest-free. Two bedrooms were double-occupancy and two bedrooms were single-occupancy. Each occupied bedroom had the required furniture and closet space for personal belongings. The windows and window screens were in good repair. One bathroom was a shared bathroom located in a hallway. This bathroom had grab bars, a shower chair, and non-slip mats. The second bathroom was connected to the master bedroom. The bathrooms were clean and the water temperature at the bathroom sink was 109 degrees Fahrenheit.

Lisa Rios	TELEPHONE: (916) 969-9685
Ellen Lindstrom	TELEPHONE: (916) 809-2109
	DATE: 07/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025

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	FACILITY NUMBER: 507001187
	VISIT DATE: 07/15/2025

NARRATIVE

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The LPA observed that the temperature in the house was set at 76 degrees Fahrenheit. There were three smoke detectors -one in the hallway near the bedrooms, one in the family room, and one in the living room. The LPA tested the detectors -all three are interconnected, are operable, and sounded an alarm. There is a carbon monoxide detector in the hallway as well, which sounded an alarm when tested. The fire extinguisher was located in the front living room. It was last serviced on 5/25/2025 by Jorgensen Co. The facility has conducted fire drills on a quarterly basis.

The LPA toured the kitchen. The kitchen is clean, the appliances are operable, and the trash can had a lid on it. There is a seven-day non-perishable and two-day perishable supply of food located in the refrigerator/freezer, kitchen cabinets, and in a locked pantry in the kitchen. The refrigerator was thirty-seven degrees Fahrenheit and the freezer was zero degrees Fahrenheit. Kitchen cleaners were locked beneath the kitchen sink.

The LPA toured the living room, dining room, and family room, which contained enough furniture for all residents, including a dining table and chairs, two couches, and recliners. The rooms are clean and windows let in natural light. The LPA toured the garage. The LPA observed additional food in a refrigerator/freezer and tall cabinets, as well as cleaners in a locked cabinet in the garage.

The LPA toured the back yard, which included a concrete patio and walkways that were free of obstruction. There were chairs, a table, and large shade umbrella for resident use. There were ornamental plants planted along the backyard fence.

The LPA inspected the central medication storage area. The first aid kit contained all the required items. Residents’ medication is kept in a locked cabinet in the living room. Each resident’s medication is stored separately in its original containers with intact labels. The LPA inspected one resident’s medication in depth. The medication counts matched the medication prescription lables.

The LPA reviewed records for three residents and three staff. The LPA observed that the records were organized and complete. All staff associated with the facility have criminal background clearances, current first aid/CPR certifications, and proof of annual training.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Ellen Lindstrom	TELEPHONE: (916) 809-2109
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025

LIC809 (FAS) - (06/04)

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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	FACILITY NUMBER: 507001187
	VISIT DATE: 07/15/2025

NARRATIVE

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The LPA requested that updated copies of these documents be submitted to Licensing by 5:00 PM on 07/29/2025. These documents can be emailed to LPA at ellen.lindstrom@dss.ca.gov.

(1) LIC 308 Designation of Facility Responsibility
(2) Copy of a current Administrator Certificate
(3) LIC 500 Personnel Report
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Liability Insurance
(6) LIC 309 Administrative Organization

As a result of this inspection, no deficiencies were cited. The facility was in compliance with California Code of Regulations (CCR), Title 22, Division 6.

An exit interview was conducted with the DFA, to whom a copy of this LIC809 report was provided. Their signature below confirms receipt of this document.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Ellen Lindstrom	TELEPHONE: (916) 809-2109
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025

LIC809 (FAS) - (06/04)

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