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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005492
Report Date: 01/26/2022
Date Signed: 02/08/2022 02:23:31 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:
01/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Kenroy AndersonTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Charlie Yang made an unannounced visit on 01/26/2022 for the purpose of conducting a Case Management visit. LPA Yang met with facility representative Kenroy Anderson and explained the reason for this visit.

On 06/09/2021 an Office meeting was held with the Licensee Marinela Placintar, the RO and DSS Auditors. During the meeting, the RO explained the audit findings and related expectation of financial monitoring of this facility for one year. Licensee Placintar was advised of documents that needed to be provided to the Audits Department along with the dates expected to submit them to this Department. The Audits Department also sent emails to Licensee Placintar reminding her of the deadlines.

The documents required for the solvency monitoring were as followed:

· LIC 401


· LIC 402
· Rent roll
· Utility statements
· Food receipts
· Monthly and quarterly bank statements

These documents were to be submitted quarterly and were due for the third quarter as of October 15, 2021. As of this date, these documents have not been received.

The following deficiencies were cited on the following LIC 809-D per Title 22, Division 6 of the California Code of Regulations.

An exit interview was conducted with the facility representative Kenroy Anderson and a copy of this report, along with appeal rights, was provided.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/02/2022
Section Cited

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87755 Inspection Authority of the Licensing Agency
The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections
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87412(f), 87506(d), and 87508(b).
This facility Licensee failed to meet the set deadlines for submission of all requested forms and documents into CCL.
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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: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2022
LIC809 (FAS) - (06/04)
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