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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700162
Report Date: 08/31/2021
Date Signed: 08/31/2021 05:37:27 PM

Document Has Been Signed on 08/31/2021 05:37 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 HOME CARE VIIIFACILITY NUMBER:
502700162
ADMINISTRATOR:PLACINTAR, MARINELAFACILITY TYPE:
740
ADDRESS:3013 QUEENS GATE COURTTELEPHONE:
(209) 495-2504
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 6DATE:
08/31/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Marinela Placintar, Administrator TIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced annual / Infection Control visit on this date. LPA met with Marinela Placintar, Administrator.
LPA conducted gateway questions prior to visiting facility. AD completed symptom check upon entry and sign in sheets available to document all visitors.
LPA and AD, inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, and dining/ living room areas.
LPA observed sufficient 7 days non-perishable and 2 days perishable food supplies.. Hot water temperature measured 115.7 degrees in residents bathroom with the AD.
Last Fire Drill conduced dated 05/01/21. Fire extinguisher maintained 7/20/2021.
Fire alarm and carbon monoxide functional. LPA observed sharps and toxins locked.
LPA and AD observed centrally stored medications.
LPA reviewed 2 staff and 6 resident files. LPA observed all staff files complete. Administrator Certificate valid until 6/23/2022.
Staff and visitors enter the facility through ringing the locked front door, sanitizer and thermometer were observed. COVID signs posted in front entry way. Sign in sheets available at entry way. All persons in facility fully vaccinated LPA observed 30 days PPE supply.
LPA observed resident in room sleeping in recliner. File review had no exception on file for recliner use. AD stated they were not aware they needed to request an exception. AD stated resident is on hospice and recliner was brought in 2 weeks ago..
Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with AD and a copy of report given via email.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2021
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 08/31/2021 05:37 PM - It Cannot Be Edited


Created By: Arlene D Garcia On 08/31/2021 at 01:52 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 HOME CARE VIII
FACILITY NUMBER: 502700162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2021
Section Cited

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Waivers and Exceptions
(b) The Department shall have the authority to approve the use of alternate concepts, programs, services, procedures, techniques, equipment, space, personnel qualifications or staffing ratios, or the conducting of experimental or demonstration projects under the following circumstances:
(2) The applicant or licensee shall submit to the Department a written request for a waiver or exception, together with substantiating evidence supporting the request.
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This requirement is not met as evidenced by: Based on interviews and records review, the administrator did not ensure facility has an approved exception letter from Community Care Licensing for the use of recliners in lieu of beds. This posed a potential health and safety risk to the resildents.
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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:Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2021


LIC809 (FAS) - (06/04)
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