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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004860
Report Date: 12/30/2021
Date Signed: 12/30/2021 09:59:30 AM

Document Has Been Signed on 12/30/2021 09:59 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:GOLDEN AGE IVFACILITY NUMBER:
507004860
ADMINISTRATOR:JONALYN REGALADOFACILITY TYPE:
740
ADDRESS:3109 IRON GATE DR.TELEPHONE:
(209) 495-2504
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 6DATE:
12/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Ken Roy Anderson, House Manager S2 TIME COMPLETED:
09:48 AM
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Licensing Program Analyst (LPA) Arlene Garcia arrived at this facility unannounced to conduct a case management visit. LPA met with Howard Livingstonl, Caregiver (S!) and explained the purpose of the visit.

LPA Garcia toured the facility with S1. COVID wellness check conducted. Sufficient PPE supplies.LPA observed comfortable living accommodations. LPA observed 2-day perishable and 7-day non-perishables. LPA observed lights functional. During this visit, it appeared that staff was sufficient. S1 reported there was a sufficient number of staff. S1 reported S1 gets paid on time. S1 reported S1 had no issues or concerns.

LPA advised Ken Roy Anderson, House Manager S2 that the Department is performing Golden Age facilities 3rd quarter, 2021 financial monitoring review. LPA requested the Administrator provide the following documents for period July - September / 2021. Administrator AD to submit to the Department no later than the close of business day on Monday January 3rd, 2022.
1. LIC 401/401A Form for the month of September 2021.
2. LIC 403/403 A Form for the month of September 2021.
3. All utility monthly billing statements including cable, water, garbage, electricity
and gas for the period from July 2021 to September 2021.
4. Monthly Bank Statements for period from July 2021 to September 2021.
5. All food receipts for all the facilities for period from July 2021 to September 2021
6. Rental Roll including resident name and rental payment for the period from July
2021 to September 2021.

Exit interview conducted with Ken Roy Anderson, House Manager S2. . Copy of report provided.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2021
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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