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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005492
Report Date: 10/24/2023
Date Signed: 10/24/2023 01:35:03 PM


Document Has Been Signed on 10/24/2023 01:35 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 VIFACILITY NUMBER:
507005492
ADMINISTRATOR:TRAIAN OANCEAFACILITY TYPE:
740
ADDRESS:2008 DAMASK COURTTELEPHONE:
(209) 495-2504
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 6DATE:
10/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kenroy AndersonTIME COMPLETED:
01:30 PM
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On 10/24/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA was greeted by Staff Member (SM), Farah Bailey and explained the purpose of the visit. LPA asked that SM Bailey call the Facility Designated Administrator to inform them that CCL was present. Shortly after, LPA met with Facility Designated Representative (FDR), Kenroy Anderson and explained the purpose of the visit. There was one other staff member present at the facility, Raffy Corla.
Shortly later, LPA met with Licensee, Marinela Placintar.
LPA reviewed 6 resident files and 3 staff files. 5 out 6 resident files did not have a complete 602, Pre-Apprasial, and Needs and Services Plan. 3 out 3 staff files were complete and up to date.
It was learned that the facility does not have an administrator that does not have a current administrator certificate.
A tour of the facility was conducted.
A tour of the kitchen was toured. Knives were observed to be locked and made inaccessible. Food supply was observed to ensure that there was a 2 day supply of perishable food supply and 7 day non-perishable food supply. The refrigerator was observed to have a flat of eggs, 2 loafs of bread, a gallon of milk, 2 half empty containers of juice, half a bell pepper, half of a onion, and a head of lettuce.
A tour of the backyard was conducted. LPA observed the cement walkway was lifted about 5 inches off the original pavement. It was observed by the LPA that there were miscellaneous items such as floss, receipts, batteries, bottle caps all throughout the fences and front of the facility.
A tour of the garage was conducted. An additional regriferator unit was observed. Additional hygiene items were identified.
A tour of the laundry was conducted. Toxins, laundry supplies, and other cleaning supplies were observed to be locked and made inaccessible.
A tour of the resident bedrooms was conducted. LPA observed a strong smell of urine in 3 out of 4 bedrooms. Furniture and furnishings were observed to be in good repair and meet the residents needs.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
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 VI
FACILITY NUMBER: 507005492
VISIT DATE: 10/24/2023
NARRATIVE
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A tour of the bathrooms were conducted. Hot water temperature was taken to ensure compliance with Title 22 regulations.
A medication cabinet was located in the kitchen. Along with the Facility Designated Representative, LPA observed, compared, and reviewed medication with medication dispensing logs. First aid kit was reviewed and had all the required components.
Fire extinguisher was observed and was last serviced by Jorgenson Co on 02/27/2023 and is in compliance at this time. Smoke detectors and carbon monoxide was observed to be in working condition.
The following forms and documents were requested to be updated and submitted into CCL

-LIC 308

-LIC 400

-LIC 500

-LIC 610

-Liability Insurance

Per California Code of Regulations (CCR) – Title 22 – Division 6, Chapter 6, deficiencies were observed during today’s visit. Citations can be found on the LIC 809 – D. Failure to correct deficiencies may result in civil penalties. Appeal Rights were provided to facility. An exit interview was held, and a copy of the report was provided in-person and sent via email.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/24/2023 01:35 PM - It Cannot Be Edited

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 VI
FACILITY NUMBER: 507005492

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by using a resident bedroom as a staff bedroom. Based on facility records, the bedroom nearest to the laundry room has been approved as a resident bedroom rather than a staff bedroom. This poses a immediate health,safety and person rights risks to persons in care.
POC Due Date: 10/25/2023
Plan of Correction
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Licensee shall provide a statement of correction and move the staff bedroom to the correct bedroom based on facility sketch by the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/24/2023 01:35 PM - It Cannot Be Edited

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 VI
FACILITY NUMBER: 507005492

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not ensuring that the facility was in a clean, safe and sanitary condition at all times. It was observed that the cement walkway is lifted about 6 inches off the ground, there was trash around the back yard, and LPA observed a strong smell of urine in 2 out 4 resident bedrooms.
POC Due Date: 11/24/2023
Plan of Correction
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Licensee shall provide a plan of correction regarding the following items. Services rendered must be sent to the LPA by the POC date.
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section above by ensuring that 5 out 6 residents have a completed pre-admission appraisal. This poses a potential health, safety and personal rights risks to persons in care.
POC Due Date: 11/24/2023
Plan of Correction
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Licensee shall provide a statement of correction to the LPA by POC date. Licensee shall complete pre-appraisal for all residents. Copies of pre-appraisal shall provide to the LPA by POC date.
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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 10/24/2023 01:35 PM - It Cannot Be Edited

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 VI
FACILITY NUMBER: 507005492

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not ensuring that 5 out 6 residents had a current medical assessment. This poses a potential health, safety and person rights risks to persons in care.
POC Due Date: 11/24/2023
Plan of Correction
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Licensee shall provide a statement of acknowledgement and provide updated medical assessment to LPA by the POC date.
Type B
Section Cited
CCR
87457(c)(1)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in by not ensuring that a current needs and services plan was conducted for 5 out 6 residentse. This poses a potential health, safety, and personal rights risks to persons in care.
POC Due Date: 11/24/2023
Plan of Correction
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Licensee shall provide a statement of acknowledgement and provide updated needs and services plan to LPA by the POC date.
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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 10/24/2023 01:35 PM - It Cannot Be Edited

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 VI
FACILITY NUMBER: 507005492

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not ensuring there was enough food supply for the residents in care. This poses an immediate health, safety and personal rights risks to persons in care.
POC Due Date: 10/25/2023
Plan of Correction
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Licensee shall provide a statement of acknowledgement. Proof of purchase and a picture of food purchased must be provided to the LPA by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6