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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
502700437
Report Date:
02/26/2024
Date Signed:
02/26/2024 04:19:58 PM
Document Has Been Signed on
02/26/2024 04:19 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 SOUTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
GOLDEN AGE 9
FACILITY NUMBER:
502700437
ADMINISTRATOR:
KENROY ANDERSON
FACILITY TYPE:
740
ADDRESS:
4121 ACCLAIM CT
TELEPHONE:
(209) 495-2504
CITY:
MODESTO
STATE:
CA
ZIP CODE:
95356
CAPACITY:
6
CENSUS:
DATE:
02/26/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:40 AM
MET WITH:
Marinela Placintar
TIME COMPLETED:
04:30 PM
NARRATIVE
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On 2/26/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with Licensee Marinela Placintar and explained the purpose of today's visit.
LPA Jensen toured the grounds and physical plant. The grounds were observed to be well maintained and all paths were free of obstruction. There is outdoor furniture and shaded areas available for clients to enjoy outdoor activities. LPA Jensen toured the interior of the facility. The facility sketch was observed to reflect the current layout. There is hospice waiver for 4. The current census is 6. The facility was observed to be sanitary and free of odor. The layout of the physical plant is very open and easily accommodates residents with specialized mobility needs. The facility had adequate lighting and furniture. All furniture was observed to be in good repair. The facility maintains a 2 day supply of perishable food and a 7 day supply of non-perishable food. There was no expired food observed.
LPA Jensen reviewed the Emergency disaster plan and determined it to be in compliance. LPA Jensen reviewed the fire drill log and determined it to be in compliance. The smoke detector was determined to be in good working order. The carbon monoxide detector was determined to be in good working order. The first aid kit was determined to be complete. All sharp objects and toxins were observed to be locked and inaccessible to residents in care. Water temperature was measured at 115 degrees.
LPA Jensen reviewed 5 of 5 staff files. 2 of 5 staff files were missing health screens. Technical assistance was provided. LPA Jensen reviewed 6 of 6 resident files. 6 of 6 files had Needs and Service Plans that were not signed by the resident or responsible party. Technical assistance was provided. 1 of 6 residents did not have a TB test on file. 1 of 6 residents did not have an LIC 602 within the last 12 months.
SUPERVISORS NAME
:
Lisa Rios
LICENSING EVALUATOR NAME
:
Maja Jensen
LICENSING EVALUATOR SIGNATURE
:
DATE:
02/26/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/26/2024
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
6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
GOLDEN AGE 9
FACILITY NUMBER:
502700437
VISIT DATE:
02/26/2024
NARRATIVE
1
2
3
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5
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LPA Jensen interviewed 1 client and 1 staff member. No other residents of staff were available.
The inspection tool was used during the course of this visit. LPA Jensen requested and received a copy of the liability insurance and the LIC 500.
An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME
:
Lisa Rios
LICENSING EVALUATOR NAME
:
Maja Jensen
LICENSING EVALUATOR SIGNATURE
:
DATE:
02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/26/2024
LIC809
(FAS) - (06/04)
Page:
2
of
6