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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507206765
Report Date: 10/21/2024
Date Signed: 10/22/2024 08:07:49 AM


Document Has Been Signed on 10/22/2024 08:07 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
10/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Marinela Placintar TIME COMPLETED:
03:00 PM
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On 10/21/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA met with Licensee, Marinela Placintar and explained the purpose of the visit.

Current census was 5. A brief of interview with Licensee Placintar was conducted.

The purpose of the visit was to follow up on an incident that was reported by the Licensee to the department on 10/21/2024.

During the course of this visit, LPA obtained the following information for R1:
-ID/Emergency Contact Sheet
-Pre-Appraisal
-Needs and Services Plan
-Hospice Care Plan
-Any and All incident reports pertaining to R1

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 Licensee, Marinela Placintar.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2024
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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