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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507005492
Report Date: 09/22/2025
Date Signed: 09/25/2025 11:45:55 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/29/2025 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250729092521
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:
09/22/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Venice Andrews TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility did not report incident
INVESTIGATION FINDINGS:
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On 09/22/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Venice Andrews and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegation above.
Current census was 6. A brief interview with FDA Andrews was conducted.
It was alleged that the facility did not report an incident. Based on interviews conducted, it was admitted that the incident report regarding R1 for an incident that occurred on 07/12/2025 was not sent to the department. In addition, the department did not receive an incident report until 08/06/2025. Based on the information gathered, the facility did not report incident.
Based on observations, review of records and information gathered through interviews, the above allegations were SUBSTANTIATED meaning that there was a preponderance of evidence to prove that the allegations occurred as alleged. The following deficiencies were cited per Title 22 Division 6 of the California Code of Regulation.
An exit interview was conducted, a copy of this report and appeals rights were provided to the facility at the end of this visit.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 27-AS-20250729092521
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/22/2025
Section Cited
CCR
87211(a)(1)
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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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Licensee shall send in an statement of correction to this LPA by POC date.
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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.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/29/2025 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250729092521

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:
09/22/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Venice Andrews TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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2
3
4
5
6
7
8
9
Staff bit resident
Staff took residents phone away
INVESTIGATION FINDINGS:
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13
On 09/22/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Venice Andrews and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegation above.

Current census was 6. A brief interview with FDA Andrews was conducted.
Allegation: Staff bit resident
It was alleged that the staff bit resident. During the course of this investigation the department conducted interviews. Based on interviews conducted, it was reported that on July 12, 2025, at approximately 6:35 PM, facility staff were assisting Resident 2 (R2) with their personal care needs in their room. While receiving care, R2 reportedly began making noises, which is part of the resident’s way of communicating. At that time, Resident 1 (R1) began yelling and told staff to stop while picking up their cane.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20250729092521
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/22/2025
NARRATIVE
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According to staff, R1 approached them, pulled their hair, and struck them in the face while they were still assisting R2. In an effort to release R1's grip, the staff member attempted to hold R1’s hands.

Additionally, during an interview, R1’s responsible party confirmed that R1 has a history of being physically aggressive toward facility staff. However, the responsible party denied any allegations that a staff member bit a resident.

Based on the information gathered, it is unclear if the staff bit resident.

Allegation: Staff took residents phone away.

It was alleged that the facility staff took residents phone away. During the course of this investigation, the department conducted interviews. Based on interviews conducted, it was reported that Resident 1 (R1) consistently attempted to contact emergency services using their personal phone. It was determined that both R1’s responsible party and emergency services agreed that R1 should use the facility phone when seeking assistance. This agreement helped reduce the frequency of unnecessary calls to emergency services. R1’s responsible party also denied any claims that facility staff had taken away R1’s personal phone. Based on the information gathered, it is unclear if the facility staff took residents phone away.

Based on information provided through interviews and records reviewed, this allegation is deemed UNSUBSTANTIATED, meaning that there was not a preponderance of evidence to prove or disprove that the allegation occurred as reported.

There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4