<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920176
Report Date: 11/06/2025
Date Signed: 11/06/2025 03:51:42 PM

Document Has Been Signed on 11/06/2025 03:51 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GOLDEN AGE LIVING 1FACILITY NUMBER:
345920176
ADMINISTRATOR/
DIRECTOR:		SOUMAHORO, MUAMOUDOU AFACILITY TYPE:
740
ADDRESS:3375 LA CADENA WAYTELEPHONE:
(916) 389-9683
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY: 6CENSUS: 6DATE:
11/06/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:32 PM
MET WITH:Camille McFarlaneTIME VISIT/
INSPECTION COMPLETED:
04:05 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 November 6, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a complaint investigation when LPA observed the following deficiencies. LPA met with staff and explained the purpose of the visit.

Today's visit, LPA was conducting interviews and observed medications to be in R1's bedroom. LPA observed laxative and a bottle of Tylenol to be present in the room. Upon file review of R1's LIC 602, it revealed that R1 is unable to administer own medication and unable to store own medication.

When LPA and staff walked to the garage to look for personal hygiene product and paper towels for residents in care, LPA observed facility did not have any paper towels available for resident usage. LPA was informed it was a frequent issue that there was no paper towel and/or hand towels for usage. During the inspection of the garage, LPA observed boxes of residents overflow medications. LPA was informed this is where medications are centrally stored.

LPA informed staff that all medications in R1's room is to be removed and to be centrally stored and locked. LPA informed staff that the garage is not an adequate space for medication as garage is not locked where residents can easily access medications.

As a result of today's inspection, deficiencies cited. Please see LIC 809-D.

Exit interview and a copy of the report and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Cassie Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
Document Has Been Signed on 11/06/2025 03:51 PM - It Cannot Be Edited


Created By: Cassie Yang On 11/06/2025 at 01:55 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN AGE LIVING 1
FACILITY NUMBER: 345920176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2025
Section Cited
CCR
87465(h)(1)(B)

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (B) Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Medications were removed from R1's bedroom and centrally stored immediately.

Licensee is to audit all residents bedrooms to ensure there are no medications in their rooms as all residents in care are unable to store own medications. Notification of completion is due within 24 hours on November 7, 2025.
8
9
10
11
12
13
14
Based on observation and file review, Licensee did not comply as R1 is unable to store own medication but laxative and tylenol was observed in the room which poses an immediate risk for residents in care.
8
9
10
11
12
13
14
Failure to correct by plan of correction due date may result to a civil penalty of $100 per day until received.
Type A
11/07/2025
Section Cited
CCR87465(h)(2)

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee is to relocate all medications to a centrally stored safe and locked space. Proof of the relocation is to be submitted to LPA within 24 hours on November 7, 2025.
8
9
10
11
12
13
14
Based on observation, Licensee did not comply as the centrally stored medications are not in a locked space which poses an immeidtae risk for residents in care.
8
9
10
11
12
13
14
Failure to correct by plan of correction due date may result to a civil penalty of $100 per day until received.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Cassie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 11/06/2025 03:51 PM - It Cannot Be Edited


Created By: Cassie Yang On 11/06/2025 at 02:35 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN AGE LIVING 1
FACILITY NUMBER: 345920176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2025
Section Cited
CCR
87307(a)(3)(C)

1
2
3
4
5
6
7
87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:
(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee is to purchase adequate supply of hand towels and/or paper towels for residents in care.

Licensee is to submit proof of purchase to LPA by November 10, 2025.
8
9
10
11
12
13
14
Based on observation and interview, Licensee did not comply as facility did not have any paper towels and/or hand towels available for residents in care until a resident's family member arrived with paper towels which poses a potential risk for residents in care.
8
9
10
11
12
13
14
Failure to correct by plan of correction due date may result to a civil penalty of $100 per day until received.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Cassie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4