Community Care Licensing

Document Has Been Signed on 08/05/2021 05:21 PM - It Cannot Be Edited

FACILITY NAME:	GOLDEN AGE IV		FACILITY NUMBER:	507004860
ADMINISTRATOR:	JONALYN REGALADO		FACILITY TYPE:	740
ADDRESS:	3109 IRON GATE DR.		TELEPHONE:	(209) 495-2504
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY: 6		CENSUS:	DATE:	08/05/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Administrator, Marinela Placintar		TIME COMPLETED:	03:30 PM

SUPERVISORS NAME: Stephenie Doub LICENSING EVALUATOR NAME: Arlene D Garcia LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2021

Link to Parent Document Below:

FACILITY NAME: GOLDEN AGE IV	FACILITY NUMBER: 507004860
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/05/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/05/2021 Section Cited	1 2 3 4 5 6 7	87411(f) (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
	8 9 10 11 12 13 14	This regulation was not met by evidence by: LPA reviewed the staff files. Two staff did not have a completed Health Screen. This poses an immediate risk to the residents in care.	8 9 10 11 12 13 14
Type B 08/05/2021 Section Cited	1 2 3 4 5 6 7	87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. (A) Physician-prescribed orthopedic devices such as braces or casts, used for support of a weakened body part or correction of body parts, are considered postural supports.
	8 9 10 11 12 13 14	This regulation was not met by evidence by: LPA observed a hospital bed in R1 Room. LPA reviewed R1 file and no documentation in staff file.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Stephenie Doub LICENSING EVALUATOR NAME: Arlene D Garcia LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2021