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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001187
Report Date: 11/05/2020
Date Signed: 11/06/2020 10:59:52 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:
11/05/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Marinela PlacintarTIME COMPLETED:
04:00 PM
NARRATIVE
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On 11/05/2020 an audit solvency virtual visit was conducted with Marinela Placintar. Attendees are as follows: Regional Manager Krystall Moore, LPM Czarrina Camilon-Lee, LPM Stephen Richardson, LPA Avelina Martinez, Jacqueline Juarez, llyas Hussein, Jude De La Concepcion, Hao Nguyen, Tracy Thompson.

Throughout the course of the audit investigation, the Department conducted interviews and Document Link Iconreviewed facility documents. Based on the audit investigation, the following deficiencies were substantiated:

            1. The licensee does not have an adequate financial plan to meet operating costs for care of residents.
            2. Facility licensee did not comply with inspection authority of the licensing agency as required.
            3. The administrator is not meeting the required administrator qualifications and requirements.

Financial statements obtained throughout the audit investigation revealed, the licensee does not have an adequate financial plan in place. Furthermore, the licensee does not have sufficient resources to meet the operating costs for all residents residing in Golden Age facilities: 1 thru 9. Bank statements indicate the licensee had a negative daily balance over a five-month period in 2020. In addition, the licensee incurred multiple overdraft fees during this period.

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SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020
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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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: 11/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
11/27/2020
Section Cited

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87213 Finances: The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents; shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency...
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This requirement is not met as evidenced by:Based on interviews and file reviews, the licensee did not ensure to have the sufficient resources to meet operating costs for care of residents. Over a five-month period, the facility had a daily negative balance This posed a potential health and safety risk to residents in care.

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Licensee agrees to email LPA a written financial plan for all facilities .
Licensee agrees to email POC by 11/27/2020.
Request Denied
Type B
11/27/2020
Section Cited

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87405 Administrator - Qualifications and Duties:(d) The administrator shall have the qualifications specified...(2) Knowledge of and ability to conform to the applicable laws…(3) Ability to maintain or supervise the maintenance of financial…records. (5)Good character...
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This requirement is not met as evidenced by: Based on interviews and records review, the licensee didn't ensure maintain records, comply with audit request, and have good character. This posed a potential health/safety risk to residents in care.
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Licensee agrees to provide a written statement that she has reviewed Administrator - Qualifications and Duties regulation. Licensee agrees to email LPA POC by 11/27/2020
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: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2020
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: 11/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
11/20/2020
Section Cited

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87755 Inspection Authority of the Licensing Agency: (c) The licensing agency shall have the authority to inspect, audit....This requirement is not met as evidenced by:Based on interviews and documentation...
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requests by the Department, the licensee did not provide the Department with the requested documentation. This posed a potential health and safety risk to residents in care.
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Licensee agrees to email POC by 11/20/2020.

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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: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2020
LIC809 (FAS) - (06/04)
Page: 3 of 5
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
VISIT DATE: 11/05/2020
NARRATIVE
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Marinela Placintar has agreed to provide the above-mentioned documents. The Audit Department requests all documents be submitted to auditor, Xiao Ni, by December 5, 2020; 30 days from today’s date.

As a result of this audit investigation, deficiencies are cited on the LIC 9099-D, per Title 22 Regulations. An appeals right document was given to the licensee. An exit interview was conducted with Marinela Placintar and a copy of this report was provided to Marinela Placintar via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020
LIC809 (FAS) - (06/04)
Page: 4 of 5
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
VISIT DATE: 11/05/2020
NARRATIVE
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Moreover, the Department’s auditor contacted the licensee several times via email, phone calls, and an audit engagement certified letter to request documents. On May 19, 2020, the Department auditor conducted a follow up call in regards to previous documentation requests. On this follow up call, Marinela Placintar stated, “she would not do anything for the solvency audit.” As of today, Marinela Placintar has not submitted the requested audit documents to the Department.

Licensee failed to cooperate with the solvency audit and has failed to conform to the inspection authority regulation. The Audit Department subpoenaed the licensee’s bank statements. In addition, the licensee did not have good character and a continuing reputation of personal integrity during the audit investigation. As such, the unwillingness to cooperate with the audit investigation and provide documentation demonstrates the lack of the required administrator qualifications and duties.

In addition, the Centralized Application Bureau (CAB) informed Marinela Placintar that she would need to comply with CAB requirements for Golden Age 10 application. The Audit Department has requested the following documentation:

            1. LIC 401 Operating Income Statement for all facilities for the month of September 2020
            2. LIC 403 Balance Sheet for the month of September 2020 as a corporation for all or by individual facility
            3. Food receipts for facilities for the month of September 2020
            4. Rent Roll for September 2020 by facility for the period of July – September 2020
            5. Utility statements – Electricity, Gas, Water Sewer and Garbage (if paid by licensee) Cable, and facility phone bill for all facilities
            6. Bank Statements for all accounts July, August, and September 2020

Continued...
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020
LIC809 (FAS) - (06/04)
Page: 5 of 5