502700820-3-30-2026-27-AS-APAA-DSNQHY-20260330121151

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700820
Report Date: 03/30/2026
Date Signed: 03/30/2026 12:12:11 PM

Document Has Been Signed on 03/30/2026 12:12 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 10		FACILITY NUMBER:	502700820
ADMINISTRATOR/ DIRECTOR:	PLACINTAR, MARINELA		FACILITY TYPE:	740
ADDRESS:	3213 INVERNESS ST.		TELEPHONE:	(209) 495-2504
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY: 6		CENSUS: 4	DATE:	03/30/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Joseph Ramasanta		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 03/30/2026, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA Pascua was greeted by Caregiver, Marlene Mclean and explained the purpose of the visit. LPA Pascua asked Caregiver Mclean to inform the Facility Designated Administrator (FDA), Marinela Placintar and explained the purpose of the visit. It was learned that a new administrator has been put in place for this facility. LPA Pascua asked FDA Placintar to inform the new administrator, Joseph Romansanta that CCL was present at this time. There was two other staff member present, Marlon Whyte and Venice Andrews. Current census was 4. This facility is licensed to serve 6 residents who are 60 and above. All 6 residents may be non-ambulatory. This facility has a Dementia Plan and has a hospice waiver for 4 residents. LPA Pascua reviewed 4 resident files. 1 out 4 resident files did not have a complete admission agreement. LPA Pascua reviewed 3 staff files. It was learned that the Facility Designated Administrators did not have a file on site. 1 out 3 staff files did not have annual dementia training as required by Title 22. The assigned Facility Designated Administrator (FDA), Joseph Romansanta has an active certificate, #6080741740 and expires on 02/22/2028. The current (FDA), Marinela Placintar also has an active administrator certificate #703557540 and expires on 06/23/2026. LPA Pascua reviewed the Medication along with the Medication Dispensing Logs with the designated staff present. Along with the staff member, the LPA observed, reviewed, and compared resident medication and electronic medication dispensing logs. LPA Pascua observed that for the month of March 2026, dates were not initiated by the facility staff for 10 out 30 days of the month. First Aid Kit was present and contained all of the required components. A tour with FDA Placintar was conducted. Fire extinguisher located in the hallway was serviced by Jorgensen Co on 06/16/2025.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 03/30/2026 12:12 PM - It Cannot Be Edited

Created By: Arielle Pascua On 03/30/2026 at 10:43 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN AGE 10	FACILITY NUMBER: 502700820
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

1569.626(a)

(a) Six hours of resident care orientation within the first four weeks of employment. All six hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not ensure that 1 out 3 staff files did not have initial annual training. This poses a potential health, safety, or personal rights risks to persons in care.
	POC Due Date: 04/13/2026
	Plan of Correction
1 2 3 4	Licensee will conduct annual training for facility staff. A copy of this training shall be sent to the LPA by POC date.

Type B

Section Cited

CCR

87412(a)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not ensure that the administrators personnel records were maintained, which poses a potential health, safety, and personsl rights risk to persons in care.
	POC Due Date: 04/03/2026
	Plan of Correction
1 2 3 4	Licensee will ensure that the administrator personnel file shall be completed and kept on site. A copy of this the file shall be sent to the LPA by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:

	Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/30/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026

LIC809 (FAS) - (06/04)

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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 10	FACILITY NUMBER: 502700820
	VISIT DATE: 03/30/2026

NARRATIVE

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Dining areas, living areas, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time.
Kitchen area was toured. LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supply to meet the residents needs. Knives were observed to be locked and made inaccessible to the residents in care.
A tour of the garage was conducted. Additional storage for supplies were identified. Additional food supply was identified.
A tour of the laundry room was conducted, laundry detergent, bleach and all other cleaning supplies were made inaccessible to the residents at this time.
A tour of the resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time. A tour of two staff bedrooms were also conducted.
A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees.
The exterior of the physical plant was in good repair with no hazards present. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL.
-LIC 308
-LIC 400
-LIC 500
-LIC 610
-Documentation supporting administration change

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.

An Exit Interview was conducted and a copy of this report and appeals rights were printed and copy was provided to the facility at the end of this visit.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/30/2026 12:12 PM - It Cannot Be Edited

Created By: Arielle Pascua On 03/30/2026 at 11:20 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN AGE 10	FACILITY NUMBER: 502700820
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(c)(3)

(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with section cited above in not ensuring that 4 out 4 resident Medication Record did not have initial on the 10 out 30 days out of the month to state that admistration of medication was conducted. This poses a potential health, safety, and personal rights risks to persons in care.
	POC Due Date: 04/10/2026
	Plan of Correction
1 2 3 4	Licensee shall ensure that all staff responsible for medication management and administrator conduct no less than one (1) hour of medication training. A copy of this training shall be sent to the LPA by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:

	Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/30/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026

LIC809 (FAS) - (06/04)

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