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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002688
Report Date: 08/28/2023
Date Signed: 08/30/2023 07:48:24 AM

Document Has Been Signed on 08/30/2023 07:48 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 IIFACILITY NUMBER:
507002688
ADMINISTRATOR:JONALYN REGALADOFACILITY TYPE:
740
ADDRESS:3112 IRON GATE DRIVETELEPHONE:
(209) 495-2504
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 5DATE:
08/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kenroy Anderson TIME COMPLETED:
12:00 PM
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On 08/28/2023 Licensing Program Analyst (LPA), Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA Pascua was greeted by House Manager, Venice Andrews, and explained the purpose of the visit. LPA Pascua asked that HM Andrews call the Facility Designated Representative, Kenroy Anderson to inform him that CCL was present. Shortly after, LPA met with FDR Anderson and Licensee, Marinela Placintar. There was one other staff member present, Donald Stewart.
This facility is licensed to serve 6 residents who are 60 or older, all of which may be ambulatory. This facility has a dementia program on file and has a hospice waiver for 4.
Current census was 5. A brief interview with Licensee Placintar was conducted.
LPA reviewed 5 resident files. It was learned that there are 2 residents receiving hospice services. 5 out 5 resident files were current and complete. LPA reviewed 3 staff files. 3 out 3 staff files are complete and up to date. Administrator holds an active and current certificate #6000942740 and expires on 06/23/2024.
A tour of the facility was conducted.
The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been annually inspected by Jorgenson Co on 02/27/2023.
The kitchen area was toured. LPA observed a non-perishable and perishable foods in the cabinets and refrigerator. Additional perishable food supplies were identified in the garage.
LPA observed a locked centralized stored medication cabinet located in the kitchen. Along with the administrator, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.
A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time.
A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 507002688
VISIT DATE: 08/28/2023
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Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.

A tour of the garage was conducted. Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.

A tour of the garage was conducted. Additional perishable food supplies were identified. Washer and dryer were identified. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.

The exterior of the physical plant was toured. 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

-Liability Insurance

As a result of this visit, no deficiencies were observed or cited during this annual visit. An exit interview was conducted and copy of the 809 and 809-C was provided to Licensee, Marinela Placintar.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
LIC809 (FAS) - (06/04)
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