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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700820
Report Date: 02/23/2022
Date Signed: 02/23/2022 01:07:06 PM

Document Has Been Signed on 02/23/2022 01:07 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: 6DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Kenroy Anderson TIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Jason Lund arrived to conduct an annual required visit. LPA was greeted by a caregiver and a short time later by Administrator Kenroy Anderson and explained the reason for the visit.

LPA and Administrator walked the facility. LPA observed Covid practices in place. Common areas were toured. Living area, recreation area, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were in good repair and able to meet the needs of the residents at this time. Resident bedroom furniture and furnishings were observed to be in good repair and able to meet the needs of the residents at this time.

Linen closet was reviewed and observed to contain a sufficient supply of sheets, blankets, and covers in order to properly meet the needs of the residents at this time.

Exterior grounds of this facility was toured. It was observed that there was outdoor furniture in place with a table and chairs in good repair at this time.

Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable food quantities. First aid kit was reviewed and observed to contain all required components at this time.

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: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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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