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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507206765
Report Date: 01/26/2022
Date Signed: 01/26/2022 04:17:37 PM

Document Has Been Signed on 01/26/2022 04:17 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 VIIFACILITY NUMBER:
507206765
ADMINISTRATOR:PLACINTAR, BIANCAFACILITY TYPE:
740
ADDRESS:1709 MABLE AVETELEPHONE:
(209) 495-2504
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 6DATE:
01/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Administrator Bianca MarinelaTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jason Lund made an unannounced visit on this day for the purpose of conducting a Case Management visit. LPA me with Administrator Bianca Marinela and explained the reason for the visit.

On 6/9/2021 an Office meeting was held with the Licensee Marinela Placintar, the RO and DSS Auditors. During the meeting, the RO explained audit finding and expectation of financial monitoring for one year. Licensee Placintar was advised of documents needing to be provided to the Audits Department along with the dates expected to submit to the Department. The Audits Department also sent emails to Licensee Placintar reminding of the deadlines.

The documents required for the solvency monitoring are as follows:

1. LIC 401-Monthly operating statement for Golden Age 5 & 6 & 10;


2. The food receipts showed the food delivered to Golden Age 10. How many residents reside at Golden Age 10 located at 3213 Inverness St, Modesto, CA;
3. Electricity Bill dated in August 2021;
4. Water Bills for the period July – September /2021 for all the facilities;
5. Bank statement account ending 3545 for July 1 – July 31/2021;
6. Xfinity Cable bills for the period July – September /2021 for all the facilities;
7. Water bills for the period July – September /2021 for all the facilities;
8. Food receipt for Golden Age 1 _ September 2021.

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

The following deficiencies were cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Bianca Marinela and a copy of this report along with appeal rights was provided.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
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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Document Has Been Signed on 01/26/2022 04:17 PM - It Cannot Be Edited


Created By: Jason Lund On 01/26/2022 at 03:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN AGE VII
FACILITY NUMBER: 507206765

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
CCR
87755(c)

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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 87412(f), 87506(d), and 87508(b).
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Licesnsee will turn requested paperwork by 2/2/2022
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This requirement is not met as evidenced by: The Department requested paperwork from the license by 10/15/21 and did not receive paperwork . This posed a potential health and safety risk to 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 Doub
LICENSING EVALUATOR NAME:Jason Lund
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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