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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004123
Report Date: 11/15/2021
Date Signed: 11/15/2021 02:09:52 PM

Document Has Been Signed on 11/15/2021 02:09 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 IIIFACILITY NUMBER:
507004123
ADMINISTRATOR:BIANCA PLACINTARFACILITY TYPE:
740
ADDRESS:3101 IRON GATE DR.TELEPHONE:
(209) 408-0428
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 5DATE:
11/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH: Marinela Placintar, AdministratorTIME COMPLETED:
12:02 PM
NARRATIVE
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Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced annual / Infection Control visit on this date. LPA was greeted by Jody-ann Orlebar, Caregiver (S1) met with Marinela Placintar, Administrator (AD).
LPA and S1 inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, and dining/ living room areas.
LPA observed sufficient 7 days non-perishable and 2 days perishable food supplies.. Hot water temperature measured 118.4 degrees in residents bathroom with the S1 which is in required range of 105 to 120 degrees.
Last Fire Drill conduced dated 11/21/21. Fire extinguisher maintained 5/05/2021.
Fire alarm and carbon monoxide functional.
LPA and S1 observed centrally stored medications.
LPA reviewed 3 staff and 4 resident files. Resident emergency contact complete. LPA observed all staff files complete. LPA observed a new hire staff working on site without a fingerprint clearance on file. AD immediately removed staff from facility for fingerprints. AD confirmed today was first day and her fingerprint appointment is scheduled for 11/15/21 at 10AM
Administrator Certificate (Bianca Placintar) valid until 8/30/2021.
All persons in facility fully vaccinated with exception of 1 resident due to religious reasons. LPA observed 30 days PPE supply. LPA observed sharps and toxins locked.
Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with AD and a copy of report given via email.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2021
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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Document Has Been Signed on 11/15/2021 02:09 PM - It Cannot Be Edited


Created By: Arlene D Garcia On 11/15/2021 at 10:11 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN AGE III
FACILITY NUMBER: 507004123

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/16/2021
Section Cited

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Fingerprint Clearance: A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another by providing the following documents to the Department: (1) A signed Criminal Transfer Request, LIC 9182 (2) A copy of the individual's (a) drivers license (b) valid ID card issued by DMV (c) valid photo ID by another state of the US
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*Fingerprint clearance requirement was not met as evidenced by two staff not having fingerprint transfer clearance. They were associated to another home owned by the same company.*
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2021


LIC809 (FAS) - (06/04)
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