<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004123
Report Date: 01/24/2024
Date Signed: 01/24/2024 11:44:00 AM

Document Has Been Signed on 01/24/2024 11:44 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marinela Placintar TIME COMPLETED:
01:00 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 1/24/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA met with Staff Member (SM) Nehomi Macfarlane and explained the purpose of the visit. LPA as SM Macfarlane to call the Facility Designated Administrator (FDA) to inform them that CCL was present at this time. Shortly after, LPA met with Licensee Marinela Placintar and explained the purpose of the visit.
There were two other staff members present at the time of this visit, Marsha Spencer and Christopher Nnam.
This facility is licensed to serve 6 non-ambulatory elderly residents at this time. This facility has a hospice waiver allowable for 2 residents at this time.
The current census was 5. A brief interview with Licensee Placintar was conducted.
LPA Pascua reviewed 4 resident files and 3 staff files. 4 out 4 residents files were current and up to date. There are currently 2 residents were receiving hospice services. LPA Pascua reviewed 3 staff files. 3 out 3 staff files were complete and up to date. The administrator does not have an active administrator certificate #6036635740 and expired on 08/30/2023, however is awaiting for the department for a renewed certificate. LPA was able to confirm that the administrator provided the department documentation and payment prior to the expiration date.
A tour of the facility was conducted.
A fire extinguisher was also observed to be in the kitchen and was annually inspected by Jorgenson Co on 03/18/2022
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.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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 III
FACILITY NUMBER: 507004123
VISIT DATE: 01/24/2024
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
26
27
28
29
30
31
32
A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time.
Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.

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.

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: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2