507005174-5-8-2023-27-AS-APAA-CRMUJZ-20230508153822

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507005174
Report Date: 05/08/2023
Date Signed: 05/08/2023 03:38:28 PM

Document Has Been Signed on 05/08/2023 03:38 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 V		FACILITY NUMBER:	507005174
ADMINISTRATOR:	OANCEA, TRAIAN		FACILITY TYPE:	740
ADDRESS:	3301 SHARON AVENUE		TELEPHONE:	(209) 495-2504
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	6	CENSUS: 5	DATE:	05/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Kenroy Anderson		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 05/08/2022 at 11:00am, Licensing Program Analyst (LPA) Arielle Pascua arrived to this facility unannounced to conduct an annual visit. LPA Pascua was greeted by staff member, Nicolette Ebanks Taylor and explained the purpose of the visit. LPA asked SM Taylor to call the Facility Designated Administrator (FDA) to inform them that CCL was present. It was learned at this time that FDA was not available at this time and CCL will be meeting with Facility Designated Representative (FDR), Kenroy Anderson. Shortly after LPA met with FDR Anderson. There was one other staff member present, Norris Walsh. This facility is licensed to served 6 residents, all of whom may be non-ambulatory. This facility has a hospice waiver for 2 and has a dementia plan on file. Current Census was 5. LPA reviewed 5 resident files. LPA reviewed 3 staff files. All files are current and up to date. 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 02/26/2023.. 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.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

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 V	FACILITY NUMBER: 507005174
	VISIT DATE: 05/08/2023

NARRATIVE

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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.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

LIC809 (FAS) - (06/04)

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