507005492-10-12-2022-27-AS-APAA-CK5UVQ-20221012155531

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507005492
Report Date: 10/12/2022
Date Signed: 10/12/2022 03:55:35 PM

Document Has Been Signed on 10/12/2022 03:55 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 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: 6	DATE:	10/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Bianca Placintar		TIME COMPLETED:	03:00 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 10/12/2022 at 1:00pm, Licensing Program Analyst (LPA) Arielle Pascua arrived at this facility unannounced to conduct an annual infection control visit. LPA Pascua was greeted by staff member, Paulette Campbell and was asked to call the Licensee, Marinela Placintar to let her know that licensing was present at this time. Upon arrival the LPA observed a centralized screening point equipped with hand sanitizer and masks. Shortly after, LPA Pascua met with Facility Designated Representative, Bianca Placintar explained the purpose of the visit. The purpose of the visit is to conduct an annual infection control visit. This facility has a hospice waiver for 3. There was one other staff member present in the facility at this time, Raffy Corla. The current census was 6. At 1:15pm, LPA Pascua initiated a a tour of the facility. At 1:15pm, LPA Pascua toured the kitchen area. LPA Pascua observed a sufficient amount of 2-day perishable food supply in the refrigerator and a 7-day non-perishable food supply in the pantry for 6 residents. Knives were observed to be locked and made inaccessible to the residents at this time. Cleaning supplies were also observed to be locked under the kitchen sink and made inaccessible to the residents in care. A fire extinguisher was also observed to be in the kitchen and was annually inspected by Jorgenson Co on 03/18/2022. At 1:20pm, LPA Pascua toured resident bedroom #1. Resident furniture was observed to be sufficient to meet their needs at this time. At 1:25pm LPA Pascua also toured a bathroom connected to resident bedroom #1. Hot water temperature was measured to be 112 degrees. Grab bars were observed to be stable and in good repair at this time. From 1:30pm-1:40pm, LPA Pascua observed a locked centralized stored medication cabinet located in the kitchen. Along with the staff member, Paulette Campbell, the LPAs observed, reviewed, and compared resident medication and electronic medication dispensing logs. First Aid Kit was present and contained all of the required components. At 1:45pm, LPA Pascua toured resident bedroom #2. Resident furniture was observed to be sufficient to meet their needs 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: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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
	VISIT DATE: 10/12/2022

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A linen closet located in the hallway and additional locked storage for cleaning supplies were identified and made inaccessible to the residents in care.
At 1:50pm, LPA Pascua toured resident bedroom #3. Resident furniture was observed to be sufficient to meet their needs at this time. LPA Pascua identified a linen closet. Linen was sufficient to meet the resident's needs at this time.
At 2:00pm, LPA Pascua toured a shared resident bathroom. Hot water temperature was measured to be 112 degrees. Grab bars were observed to be stable and in good repair at this time.
At 2:05pm, LPA Pascua toured the garage. A washer and dryer to wash residents bedding and clothing was identified. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
At 2:10pm, LPA Pascua toured the live-in staff bedrooms and bathrooms.
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.

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

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 Facility Designated Representative, Bianca Placintar.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

LIC809 (FAS) - (06/04)

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