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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004123
Report Date: 01/06/2025
Date Signed: 01/06/2025 03:45:31 PM

Document Has Been Signed on 01/06/2025 03:45 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 IIIFACILITY NUMBER:
507004123
ADMINISTRATOR/
DIRECTOR:		BIANCA PLACINTARFACILITY TYPE:
740
ADDRESS:3101 IRON GATE DR.TELEPHONE:
(209) 408-0428
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 5DATE:
01/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Marinela Placintar TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 01/06/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA was greeted by Marsha Spencer and explained the purpose of the visit.
LPA entered the facility and found that there was a power outage at this facility at this time. It was stated that that the local electrical company had turned off the electricity due to payment issues.
LPA conducted a health and safety check of all residents and found that all residents were either sleeping or sitting in the designated resident areas. LPA continued the visit and reviewed facility records.

LPA reviewed 5 resident files and 3 staff files. It was observed that 3 out 5 resident files did not have an updated needs and services plan. 3 staff files were observed to not have updated dementia training within the last year.
The administrator has an expired administrator certificate but this LPA was able to confirm that the administrator certificate was sent prior to expiration on 08/10/2023.
At 11:47am, the facility power was turned back on.
LPA conducted a tour of the facility. Smoke detectors and carbon monoxide were observed to be in working condition. Fire extinguisher was serviced on 08/21/2024 by the local fire company Jorgenson Co.
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: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2025
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN AGE III
FACILITY NUMBER: 507004123
VISIT DATE: 01/06/2025
NARRATIVE
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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.

LPA observed that the sliding glass door that leads to the backyard yard. LPA was unable to open the sliding glass door, upon inspection of the sliding glass door it was observed that the door was stopped by the a wood plank.
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

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 and a copy of this report was provided to this facility at the end of this visit.

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

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/06/2025 03:45 PM - It Cannot Be Edited


Created By: Arielle Pascua On 01/06/2025 at 12:26 PM
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 III
FACILITY NUMBER: 507004123

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/06/2025
Section Cited

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(2) Eight hours of in-service training per year on the subject of serving residents with dementia.
This is not met as evidenced by:
Based on observation and record review, this licensee did not ensure that 3 out 3 staff members did not have annual
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dementia training. This poses a potential health, safety, and personal rights risks in persons in care.
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Type B
02/06/1987
Section Cited

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(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.
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This is not met as evidenced by: Based on observation and record review, this licensee did not ensure that 3 out 5 residents did not have an updated reappraisal. This poses a potential health, safety, and personal rights risks in persons in care.
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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:Lisa Rios
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/06/2025 03:45 PM - It Cannot Be Edited


Created By: Arielle Pascua On 01/06/2025 at 12:35 PM
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 III
FACILITY NUMBER: 507004123

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/07/2025
Section Cited

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(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
This is not met as evidenced by: Based on observation, the Licensee
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did not ensure that the sliding glass door was not easily opened. LPA observed a wood plank that was prohibiting the sliding glass door from opening. This poses an immediate health, safety, and personal rights risk to persons in care.
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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:Lisa Rios
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 01/06/2025 03:45 PM - It Cannot Be Edited


Created By: Arielle Pascua On 01/06/2025 at 03:38 PM
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 III
FACILITY NUMBER: 507004123

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) ... Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, and interview the licensee did not comply with the section cited above by not ensuring that the facilities electricity was turned on at the time of the LPAs visit. It was learned that the local electric company turned off the electricity due to an issue with the payment on file. This poses an immediate health, safety, and personal rights risks to persons in care.
POC Due Date: 01/07/2025
Plan of Correction
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Licensee shall provide a statement of correction and acknowledgement to the LPA by POC date. LPA observed electricity turned back on at 11:47am.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lisa Rios
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2025


LIC809 (FAS) - (06/04)
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