507005492-10-21-2024-27-AS-APAA-DA9Q7J-20241021115513

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507005492
Report Date: 10/21/2024
Date Signed: 10/21/2024 11:55:23 AM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/21/2024 11:55 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	GOLDEN AGE VI		FACILITY NUMBER:	507005492
ADMINISTRATOR:	TRAIAN OANCEA		FACILITY TYPE:	740
ADDRESS:	2008 DAMASK COURT		TELEPHONE:	(209) 495-2504
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	6	CENSUS: 4	DATE:	10/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Marinela Placintar		TIME COMPLETED:	12:00 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 10/21/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA was greeted by Staff Member (SM), Paulette Williams and explained the purpose of the visit. LPA asked SM Williams to call the Facility Designated Administrator (FDA) to inform them that CCL was present. Shortly after, LPA met with Licensee Marinela Placintar and explained the purpose of the visit. There was one other staff member present during the course of this visit, Raffy Corla. Current census was 5. A brief interview with Licensee Placintar was conducted. LPA reviewed 5 resident files and 3 staff files. 3 out 5 resident files were not complete and up to date. 3 out 3 staff files were complete and up to date. The Facility Designated Administrator, Traian Oancea, does not have an active administrator certificate at this time. There is not an active administrator to this facility. A tour of the facility was conducted. A tour of the living room, dining room, and other areas intended for resident use were conducted. Furniture and furnishings were observed to be in good repair and meet the residents needs. Kitchen area was toured. LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supply to meet the residents needs. Knives were observed to be locked and made inaccessible to the residents in care. A tour of the garage was conducted. Additional storage for supplies were identified. Additional food supply was identified. A tour of the laundry room was conducted, laundry detergent, bleach and all other cleaning supplies were made inaccessible to the residents at this time A tour of the resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time. A tour of two staff bedrooms were also conducted.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

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

FACILITY NAME: GOLDEN AGE VI	FACILITY NUMBER: 507005492
	VISIT DATE: 10/21/2024

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 05/10/2024 and is in compliance at this time. Smoke detectors and carbon monoxide was observed to be in working condition.
The exterior of the physical plant was in good repair with no hazards present. 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

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: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

LIC809 (FAS) - (06/04)

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