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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700820
Report Date: 07/12/2021
Date Signed: 07/12/2021 12:14:52 PM

Document Has Been Signed on 07/12/2021 12:14 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 10FACILITY NUMBER:
502700820
ADMINISTRATOR:PLACINTAR, MARINELAFACILITY TYPE:
740
ADDRESS:3213 INVERNESS ST.TELEPHONE:
(209) 495-2504
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 5DATE:
07/12/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Marinela Placintar, AdministratorTIME COMPLETED:
12:02 PM
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Licensing Program Analyst (LPA) Arlene Garcia arrived to conduct an unannounced Post Licensing inspection on this date. LPA was greeted by Miesha Cooper, Caregiver. LPA met with Marinela Placintar, Administrator certificate posted #6000942740 expires 06/23/2022.

LPA reviewed the Personnel Policies, Abuse Reporting Procedures, In-Service Training and Medication Procedures during the Post-Licensing Inspection. Staff completed training from Assisted Living Certification. LPA observed Covid practices in place. LPA reviewed five resident records and two staff records. All residents and staff Covid Vaccinated. 30 day PPE supply available.

LPA observed the following posted in the entrance of the facility. See Something Say Something poster, Ombudsman poster, Reporting Requirements, Resident Personal Rights, Evacuation Routes and facility license were all posted as required.

LPA observed Fire extinguisher dated 10/01/2020. LPA observed oxygen signs posted, sharps and toxins locked. LPA observed 7 day non-perishable and 2 day perishable food supply. LPA observed functioning carbon dioxide/fire alarms functional.

No citation at this visit, exit interview held with Administrator and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
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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