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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005492
Report Date: 10/25/2021
Date Signed: 10/25/2021 03:38:41 PM

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:
10/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:MARINELA PLACINTAR, AdministratorTIME COMPLETED:
01:34 PM
NARRATIVE
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Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced annual / Infection Control visit on this date. LPA was greeted by Paulette Campbell, Caregiver (S1) and met with MARINELA PLACINTAR, Administrator (AD).

LPA and S1 inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, and dining room areas. LPA observed sufficient 7 days non-perishable and 2 days perishable food supplies.. Hot water temperature measured at 105.6 degrees in residents bathroom with the S1 which is in required range of 105 to 120 degrees. Fire Drill conduced . Fire extinguisher maintained expired 10/5/21. Fire alarm and carbon monoxide functional. LPA and caregiver observed centrally stored medications. LPA observed medications for R2 in refrigerator unlocked. LPA reviewed staff and resident files. LPA observed adequate 30 day PPE supply. LPA observed sharps locked. LPA observed toxins under sink in kitchen and under sink in residents bathroom unlocked and accessible to residents. .

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with Marinela Placintar and a copy of report given at the conclusion of the visit to administrator.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
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 3
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: 10/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2021
Section Cited

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87705(f)(2) Care of Persons with Dementia
Care of Persons with Dementia (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants shall be inaccessible to residents with dementia.
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This requirement has not been met as evidenced by: The Licensee did not ensure toxins were locked as LPA observed cleaning supplies and toxins in the living room, bathroom and garage. This violation posses an immediate health and safety risk to the residents in care.
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Type A
10/26/2021
Section Cited

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87465(h)(2) Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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This requirement has not been met as evidenced by: The Licensee did not ensure medications were locked in refridgerator. This violation posses an immediate health and safety risk to the residents in care.
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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: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 10/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/05/2021
Section Cited

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87608(a)(3) Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
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This requirement has not been met as evidenced by: The Licensee did not ensure residents using hospital beds had a physicians order. This violation posses an potential health and safety risk to the residents in care.
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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: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3