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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700437
Report Date: 07/12/2021
Date Signed: 07/12/2021 10:58:30 AM

Document Has Been Signed on 07/12/2021 10:58 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:GOLDEN AGE 9FACILITY NUMBER:
502700437
ADMINISTRATOR:PLACINTAR, MARINELAFACILITY TYPE:
740
ADDRESS:4121 ACCLAIM CTTELEPHONE:
(209) 495-2504
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 6DATE:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Marinela Placintar, AdministratorTIME COMPLETED:
11:10 AM
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Licensing Program Analysts (LPA's) Sarah Hurt and Ruth Wallace conducted an unannounced visit today for the facilities annual inspection. LPA's met with Administrator Marinela Placintar. Administrator's Certification expires 06/23/2022 .There are currently 6 residents who reside at this home and there is 3 residents are on hospice at this time. LPA'S inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguishers expired on 09/05/2020. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 115F degrees. First Aid kit is on site and complete. Toxins are locked.

This facility is operating within the scope of their license. LPA's reviewed 6 resident files. Resident's medical files and medications were reviewed. All resident files review were in compliance Two staff files reviewed and each had the required criminal record clearances. First Aid and CPR training for was current and staff has current training

The following deficiency was observed and cited per California Code of Regulations, Title 22 see LIC 809-D
Immediate civil penalty of $500 was issued on today's date.

The administrator shall send in updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-D the Emergency Disaster Plan if needed and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Administrator and copy of report left at facility.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2021
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 07/12/2021 10:58 AM - It Cannot Be Edited


Created By: Sarah Hurt On 07/12/2021 at 10:38 AM
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 9
FACILITY NUMBER: 502700437

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2021


LIC809 (FAS) - (06/04)
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