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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002688
Report Date: 07/06/2022
Date Signed: 07/07/2022 02:10:28 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/07/2022 02:10 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:GOLDEN AGE IIFACILITY NUMBER:
507002688
ADMINISTRATOR:JONALYN REGALADOFACILITY TYPE:
740
ADDRESS:3112 IRON GATE DRIVETELEPHONE:
(209) 495-2504
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 6DATE:
07/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Facility staff Kenroy Anderson TIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPA's) Sarah Hurt and Arielle Pascua conducted an unannounced visit today for the facility’s annual inspection. LPA met with facility staff Kenroy Anderson and explained the purpose for the visit. Continual Administrator's Certification for Marinela Placintar expires 06/23/2022. There are currently 6 residents who reside at this home and there is 2 residents on hospice at this time.

LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA's confirmed staff present has vaccine cards or exemptions on file. LPA's confirmed staff present is background cleared.

Facility Administrator Marinela Placintar's Administrator's Certificate expired on 06/23/2022.

LPA's observed staff did not screen at entrance for COVID 19 symptoms or ask screening questions.

LPA's observed mattresses stacked in a small room used for caregivers to sleep. LPA's reviewed facility sketch documenting the room should be a laundry room.

Continued on 9099C...
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 II
FACILITY NUMBER: 507002688
VISIT DATE: 07/06/2022
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Continued from 809...

LPA's observed several facility windows without screens.

LPA's observed several stacked mattresses near a bedroom sliding glass door. Staff 1 stated the mattresses are used to prevent Resident 1 from wondering out of the facility during the night.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

The following deficiencies were cited during today's inspection per California Code of Regulations, Title 22.

Exit interview conducted with Administrator Kenroy Anderson and a copy of this report was left at facility
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022
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Document Has Been Signed on 07/07/2022 02:10 PM - It Cannot Be Edited


Created By: Sarah Hurt On 07/06/2022 at 03:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN AGE II
FACILITY NUMBER: 507002688

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/20/2022
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. The following requirement has not been met as evidenced by:
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Licensee will send proof all facility windows have screens to LPA's by 07/20/2022 POC date.
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LPA's observed several windows did not have screens which poses a potentiol health, safety, or personal rights risk to residents in care.
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Type B
07/20/2022
Section Cited
CCR87405(a)

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87468.1 Personal Rights of Residents in All Facilities a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: The following requirement has not been met as evidenced by:
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Licensee wil send proof of mattress removal to LPA's by 07/20/2022 POC date.
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Based on LPA's observation the laundry room is being used as a staff area, and there are several mattresses stacked in a residents bedroom to prevent Resident 1 from wandering, which poses a potential health, safety, or personal rights risk to residents in care.
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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:Stephenie Doub
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022


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Document Has Been Signed on 07/07/2022 02:10 PM - It Cannot Be Edited


Created By: Sarah Hurt On 07/06/2022 at 03:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN AGE II
FACILITY NUMBER: 507002688

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/20/2022
Section Cited
CCR
87405(a)

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87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. The following requirement has not been met as evidenced by:
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Licensee will send proof of current Administrator's Certificate to LPA's by POC date 07/20/2022.
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Based on records reviewed facility Administrator Marinela Placintar's certificate expired 06/23/2022 which poses a potential health, safety, or personal rights risk to residents in care.
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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:Stephenie Doub
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022


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Document Has Been Signed on 07/07/2022 02:10 PM - It Cannot Be Edited


Created By: Sarah Hurt On 07/06/2022 at 03:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN AGE II
FACILITY NUMBER: 507002688

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/07/2022
Section Cited
HSC
1569.50(a)(3)

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Health and Safety code 1569.50 (a)(3)
Conduct Inimical: Conuduct which inimical to health, common morals, common welfare, or safety of either an individual in, or receving services from the facility or the people of the state of California. The following requirement has not been met as evidenced by:
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Facility staff agrees to train all staff on COVID 19 precautionary measures by POC date of 07/07/2022.
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Based on observation the facility did not implement COVID pre screening measures at entrance to facility this poses an immediate health, and safety risk to residents in care.
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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:Stephenie Doub
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022


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