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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001187
Report Date: 12/30/2021
Date Signed: 12/30/2021 10:45:59 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:
12/30/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Marinela Placintar, AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced case management visit to the facility on 12/30/2021 at 9:00 a.m. LPA met with Administrator Marinela Placintar and explained the purpose for today's visit. There are 6 residents currently living at the facility and 2 residents are currently on hospice care.

LPA toured the facility kitchen, bathrooms, and bedrooms. LPA observed 2 days perishable food in the refrigerator, and 7 days non perishable in facility pantry. LPA observed working gas, electricity, and warm water at the facility. LPA observed locked medication cabinet with sufficient supply of medications for facility residents. LPA observed sufficient staff working at the facility. LPA interviewed the two staff members working at the facility both stated they had no concerns at this time and are being paid correctly on time twice a month.

LPA requested Administrator Marinela submit the documents below to CCL Auditors within two days.

1. LIC 401/401A Form for the month of September 2021.
2. LIC 403/403 A Form for the month of September 2021.
3. All utility monthly billing statements including cable, water, garbage, electricity and gas for the period from July 2021 to September 2021.
4. Monthly Bank Statements for period from July 2021 to September 2021.
5. All food receipts for all the facilities for period from July 2021 to September 2021
6. Rental Roll including resident name and rental payment for the period from July 2021 to September 2021.

There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22. An exit interview was conducted with facility Administrator Marinela Placintar and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021
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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