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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004123
Report Date: 01/07/2022
Date Signed: 01/07/2022 12:17:38 PM

Document Has Been Signed on 01/07/2022 12:17 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: 6DATE:
01/07/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Marinela Placintar,TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived at the above address unannounced to conduct an annual required visit. LPA was greeted by caregiver who called Administrator Marinela Placintar, who arrives a short time later. LPA Lund explained the reason for the visit to the Administrator,

LPA and Administrator walked the facility including but not limited to the main kitchen, residents’ bedrooms and bathrooms, and dining/ living room areas.
LPA observed sufficient 7-day non-perishable and 2-day perishable food supplies. Fire extinguisher was maintenance on 5/05/2021. Fire alarm and carbon monoxide functional. LPA observed centrally stored medications.

LPA Lund and Administrator Marinela Placintar talked about the new Pins coming out.
No deficiencies where cited during today’s visit

Exit interview held with AD and a copy of report given via email.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2022
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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