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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001187
Report Date: 08/16/2024
Date Signed: 08/16/2024 03:17:11 PM


Document Has Been Signed on 08/16/2024 03:17 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 AGEFACILITY NUMBER:
507001187
ADMINISTRATOR:ELENA TRITEANFACILITY TYPE:
740
ADDRESS:3521 EFFINGHAM LANETELEPHONE:
(209) 491-0674
CITY:MODESTOSTATE: CAZIP CODE:
95357
CAPACITY:6CENSUS: 6DATE:
08/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Marinella PlacintarTIME COMPLETED:
03:30 PM
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On 8/16/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual. LPA Jensen met with Licensee Marinella Placintar and explained the purpose of today's visit.

LPA Jensen toured the grounds and observed all paths to be free of obstruction. There is a shaded area and patio furniture available for outdoor activities. All window screens were observed to be in good repair. LPA Jensen toured the interior of the facility. The facility was observed to be sanitary, free of odor and adequately furnished. LPA Jensen toured the kitchen and observed there to be 2 days of perishable of food and 7 days of non-perishable food. There was fresh produce and a variety of food options. The bathroom water temperature was 107 degrees which is within the required range of 105-120 degrees. The thermostat was set to a comfortable 72 degrees. LPA Jensen observed activities available for residents if needed. There is an adequate supply of linens available. All toxins, medications and sharp objects were locked and inaccessible to residents in care. LPA Jensen checked the smoke detector and carbon monoxide detectors and determined they are good working order.

The emergency disaster plan was reviewed and is in compliance. Fire drills are conducted on a regular basis and logged. There is an emergency supply kit that is complete and in compliance. LPA Jensen reviewed 6 of 6 resident files and found them to be complete. 6 of 6 residents are on hospice and the facility has a hospice waiver for 6. According to the physician reports there are no bedridden residents. All staff present had criminal background clearance. A hospice plan was reviewed and found to be complete.

The facility was determined to be in substantial compliance. The inspection told was used during the course of this process. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024
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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