507001187-8-17-2023-27-AS-KVIA-CUSGR6-20230817053347

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507001187
Report Date: 08/16/2023
Date Signed: 08/17/2023 05:33:52 AM

Document Has Been Signed on 08/17/2023 05:33 AM - 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	GOLDEN AGE		FACILITY NUMBER:	507001187
ADMINISTRATOR:	ELENA TRITEAN		FACILITY TYPE:	740
ADDRESS:	3521 EFFINGHAM LANE		TELEPHONE:	(209) 491-0674
CITY:	MODESTO	STATE: CA	ZIP CODE:	95357
CAPACITY:	6	CENSUS: 4	DATE:	08/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Marinela Placintar, Licensee		TIME COMPLETED:	05:00 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	On 08/16/2023 unannounced annual inspection was made to this facility by Licensing Program Analyst (LPA) Kimberly Viarella. The LPA identified herself and the purpose of the visit and asked to speak to the Designated Facility Administrator. LPA met Marinela Placintar, the Licensee. The Licensee informed this LPA that the Designated Facility Administrator, Elena Tritean's certification, # 6050936740, expired on 03/28/2023. The Administrator then provided this LPA with proof that the renewal training had been completed. The tour began with resident accommodations. Rooms were clean and had adequate furniture and lighting. There were 2 bathrooms. The LPA observed grab bars, non-skid surfaces, paper towels and soap in each. The hot water temperature was measured 112.8 degrees Fahrenheit and was in compliance. The LPA then inspected the kitchen and observed 7 days of non-perishable and 2 days of perishable food supplies. The pantry and refrigerator were also inspected and all items were packaged and dated appropriately. The LPA observed that the knives and sharps were all kept in a locked cabinet and inaccessible to residents in care at this time. LPA observed smoke and carbon monoxide detectors throughout the facility and the fire extinguisher was last inspected in 02/27/2023 by Jorgenson Co. Medications were stored in a locked closet and kept inaccessible to residents in care. The LPA inspected the medications and reviewed, storage, dosing and destruction procedures. The EMAR system and logs were also reviewed. Narcotics were kept in a locked box and stored in a refrigerator in the garage and inaccessible to residents in care. The LPA also inspected the First Aid kit which was found to be complete and in compliance.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN AGE	FACILITY NUMBER: 507001187
	VISIT DATE: 08/16/2023

NARRATIVE

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LPA completed a review of 4 staff files. All were up-to date with CPR and First Aid but were missing annual training. LPA also completed a review of 4 resident files. All were complete. LPA provided technical assistance regarding LIC 602 regarding access to hygiene items for residents in care as well as the requirements for fire clearance.

According to California Code of Regulations, Title 22, there was one deficiency observed and cited today on the LIC 809 D page.

A copy of this report and Appeal Rights were provided to the Licensee.

Exit interview.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/17/2023 05:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN AGE	FACILITY NUMBER: 507001187
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.696(a)(1)

Other Provisions

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (1) Four hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above when the LPA observed that 2 out of 4 staff files reviewed were missing the annual training poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/31/2023
	Plan of Correction
1 2 3 4	The Licensee shall submit to kimberly.viarella@dss.ca.gov a schedule of annual training activities to be conducted by an outside vendor by 08/31/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC809 (FAS) - (06/04)

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