507004860-10-21-2026-27-AS-MORA-DZ3RFK-20261021125917

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507004860
Report Date: 10/21/2026
Date Signed: 10/21/2026 12:59:37 PM

Document Has Been Signed on 10/21/2026 12:59 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	GOLDEN AGE IV		FACILITY NUMBER:	507004860
ADMINISTRATOR/ DIRECTOR:	ELENA TRITEAN		FACILITY TYPE:	740
ADDRESS:	3109 IRON GATE DR.		TELEPHONE:	(209) 495-2504
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY: 6		CENSUS:	DATE:	10/21/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Marinela Placintar		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

NARRATIVE

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On 10/21/2026, Licensing Program Analysts (LPA) Melina Oropeza arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA was met by staff and Licensee, Marinela Placintar joined 15 minutes later. LPA explained the purpose of the visit to Licensee and staff. Licensee/administrator certificate expired on 06/24/2026. LPA reviewed licensee's administrator certification status online and was unable to verify a current/pending certification. Later during the inspection, the licensee displayed information on cell phone indicating that the renewal application was pending. LPA was unable to independently verify renewal status. Licensee shall provide verification of a currently certified administrator designated to oversee facility operations and maintain the required documentation in the facility’s personnel records.

This facility is licensed to serve 6 residents ages 60 or older. This facility has a hospice waiver for 2 at any given time and a dementia plan on file. Current census of 6.

LPA and licensee inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas to ensure compliance with Title 22 regulations. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. Chemicals and medications noted to be locked to residents in care. LPA also conducted the care domain tool.

Hot water temperature was measured at 113 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. All necessary documents were in place. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.

Liza King
Melina Oropeza
	DATE: 10/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN AGE IV	FACILITY NUMBER: 507004860
	VISIT DATE: 10/21/2026

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LPA observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings.

LPA observed, fire extinguisher inspected on 07/08/2026 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance.

A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted and in good repair. No bodies of water were observed at the facility.

LPA reviewed three (3) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required.

LPA reviewed five (5) resident facility files. During records review, LPA observed 2 residents diagnosed with dementia had no current annual medical assessments (LIC 602) on file. 1 resident had no current annual medical assessment (LIC 602) on file, 1 resident's last annual medical assessment (LIC 602) was 2 years ago. LPA observed that pre- appraisals for 2 residents were completed but lacked signatures. LPA provided Technical Assistance to the administrator regarding ensuring resident appraisals are properly reviewed, signed, and maintained in resident records.

There were deficiencies observed or cited on 809-D during today's annual visit.

During today’s annual inspection LPA Oropeza followed up on licensing fees. Presently, the facility has an outstanding balance of $460. LPA met with licensee, Marinela Placintar. Community Care Licensing has sent a bill with the annual licensing fees to the licensee. However, the annual fees have not been paid as of this date. LPA informed and explained to the licensee per CCL D regulations regarding licensing fees, the failure of an applicant or licensee to pay all applicable and accrued fees, and civil penalties shall constitute grounds for denial or for of license and an effort to assist the license with prompt payment. LPA provided the pin number which can be used to pay the balance immediately to CCL D website. No citations were issued on this day. However, the following advisory was given please pay the annual licensing fees to prevent further action this is not a citation, but an advisory. Administrator agreed to pay the licensing fees by 10/22/2026 via mail. PIN #051708.
Exit interview held with licensee and copies of reports Marinela Placintar.nd appeals were left at conclusion of visit with Licensee, Marinela Placintar.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Melina Oropeza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/21/2026 12:59 PM - It Cannot Be Edited

Created By: Melina Oropeza On 10/21/2026 at 12:21 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN AGE IV	FACILITY NUMBER: 507004860
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

87705(c)(5) Care of Persons with Dementia (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in, the licensee failed to ensure that 2 residents (R1 and R2) diagnosed with dementia had current annual medical assessments (LIC 602) on file. This poses a potential health, safety, or personal rights risk to residents in care. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/28/2026
	Plan of Correction
1 2 3 4	Licensee shall schedule medcial appointments to update medical assessments (LIC 602) for R1 and R2 and inform LPA Oropeza of dates via email at Melina.Oropeza@dss.ca.gov by POC 10/28/26 by 5:00pm.

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.

	Liza King
NAME OF LICENSING PROGRAM MANAGER:

	Melina Oropeza
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2026

LIC809 (FAS) - (06/04)

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