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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004123
Report Date: 01/13/2023
Date Signed: 01/17/2023 08:31:30 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/17/2023 08:31 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:GOLDEN AGE IIIFACILITY NUMBER:
507004123
ADMINISTRATOR:BIANCA PLACINTARFACILITY TYPE:
740
ADDRESS:3101 IRON GATE DR.TELEPHONE:
(209) 408-0428
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 6DATE:
01/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Marinela PlacintarTIME COMPLETED:
11:45 AM
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On 1/13/2022 at 9:45am, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an Annual Inspection Control Visit. LPA Pascua was greeted by staff member, and was asked to call the Licensee, Marinela Placintar to let her know that CCL was present at this time. Upon arrival the LPA observed a centralized screening point equipped with hand sanitizer and masks. Shortly after, LPA Pascua met with Licensee Placintar and explained the purpose of the visit. The purpose of the visit is to conduct an annual infection control visit. This facility has a hospice waiver for 2 and a dementia program on file. There was one other staff member present in the facility at this time, Nehomi Mcfarlane.
The current administrator, Bianca Placintar, has a current certificate #6036635740 and expires on 08/302023.
The current census at this time was 6.
At 10:30am, LPA Pascua initiated a tour of the facility with Licensee Placintar.
The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been annually inspected by Jorgenson Co and is valid until 03/18/2022.
The kitchen area was toured. LPA observed a non-perishable and perishable foods in the cabinets and refrigerator. Additional perishable food supplies were identified in the garage.
LPA observed a locked centralized stored medication cabinet located in the kitchen. Along with the administrator, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.
A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time.
A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time.
Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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 III
FACILITY NUMBER: 507004123
VISIT DATE: 01/13/2023
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Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.

A tour of the garage was conducted. Additional perishable food supplies were identified.

The exterior of the physical plant was toured. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL

-LIC 308

-LIC 400

-LIC 500

-LIC 610

-Liability Insurance

As a result of this visit, no deficiencies were observed or cited during this annual visit. An exit interview was conducted and copy of the 809 and 809-C was provided to Licensee, Marinela Placintar.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC809 (FAS) - (06/04)
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