507004860-10-17-2023-27-AS-APAA-CWPTA5-20231017143259

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507004860
Report Date: 10/17/2023
Date Signed: 10/17/2023 02:33:25 PM

Document Has Been Signed on 10/17/2023 02:33 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 IV		FACILITY NUMBER:	507004860
ADMINISTRATOR:	ELENA TRITEAN		FACILITY TYPE:	740
ADDRESS:	3109 IRON GATE DR.		TELEPHONE:	(209) 495-2504
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY: 6		CENSUS: 6	DATE:	10/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:59 AM
MET WITH:	Kenroy Anderson		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 10/17/2023 Licensing Program Analyst (LPA) Arielle Pascua arrived at this facility unannounced to conduct an annual infection control visit. LPA Pascua was greeted by staff member, Kenroy Anderson and was asked to call the Licensee, Marinela Placintar to let her know that licensing was present at this time. Shortly after, LPA Pascua met with Licensee Placintar explained the purpose of the visit. The purpose of the visit is to conduct an annual infection control visit. This facility has a hospice waiver for 2 and a dementia program on file. There was one other staff member present in the facility at this time, Antonieta Gimeno. This facility has a hospice waiver for 2 and a dementia program on file. Upon arrival, LPA Pascua learned that there are currently 3 residents on hospice at this time. LPA reviewed facility records which confirmed that there are 3 residents on hospice. LPA reviewed 3 resident files and 2 staff files. The Facility Designated Administrator does not have a current administrator certificate, however, has sent the department the proper documentation prior to the certificate expiring. LPA Pascua toured resident bedroom #1. Resident furniture was observed to be sufficient to meet their needs at this time. LPA Pascua also toured a bathroom connected to resident bedroom #1. Hot water temperature was measured to be 112 degrees. Grab bars were observed to be stable and in good repair 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. LPA Pascua toured the kitchen area. LPA Pascua observed a sufficient amount of 2-day perishable food supply in the refrigerator and a 7-day non-perishable food supply in the pantry for 5 residents. Knives were observed to be locked and made inaccessible to the residents at this time. Cleaning supplies were also observed to be locked under the kitchen sink and made inaccessible to the residents in care. A fire extinguisher was also observed to be in the kitchen and was annually inspected by Jorgenson Co on 03/18/2022. LPA Pascua observed a locked centralized stored medication cabinet located in the kitchen. Along with the staff member, Antonieta Gimeno, the LPAs observed, reviewed, and compared resident medication and electronic medication dispensing logs. First Aid Kit was present and contained all of the required components.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN AGE IV	FACILITY NUMBER: 507004860
	VISIT DATE: 10/17/2023

NARRATIVE

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LPA Pascua toured resident bedroom #2. Resident furniture was observed to be sufficient to meet their needs at this time.
LPA Pascua toured resident bedroom #3. Resident furniture was observed to be sufficient to meet their needs at this time. Across from resident bedroom #3 LPA Pascua identified a linen closet. Linen was sufficient to meet the resident's needs at this time.
LPA Pascua toured a shared resident bathroom. LPA Pascua also toured a bathroom connected to resident bedroom #1. Hot water temperature was measured to be 112 degrees. Grab bars were observed to be stable and in good repair at this time. Across the resident bathroom was a locked closet and LPA identified additional incontinence and cleaning supplies that are made inaccessible to the residents in care.
LPA Pascua toured the garage. A washer and dryer to wash residents bedding and clothing was identified. 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.

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

s a result of this visit, the following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.

An exit interview was conducted. A copy of the 809, 809-C, 809-D, LIC421BG and appeal rights were printed and a copy was given to the facility. The licensee was informed that a failure to correct any deficiencies by plan of correction due date(s) may result in civil penalties.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/17/2023 02:33 PM - It Cannot Be Edited

Created By: Arielle Pascua On 10/17/2023 at 11:28 AM

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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN AGE IV	FACILITY NUMBER: 507004860
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87455(b)(8)

(8) Persons who have been diagnosed as terminally ill and who have obtained the services of hospice, certified in accordance with federal medicare conditions of participation and licensure, provided the licensee has obtained a facility hospice care waiver in accordance with the provisions of Section 87632, Hospice Care Waiver, and hospice care is being provided in accordance with the provisions of Section 87633, Hospice Care for Terminally Ill Residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in by not ensuring that there were only 2 hospice residents at the facility. The facility currently has a hospice waiver for 2 and currently has 3 residents on hospice. This poses an immediate health, safety, and personal rights risk in care.
	POC Due Date: 10/17/2023
	Plan of Correction
1 2 3 4	Licensee shall provide a statement of correction and acknowledgement stating that they have read the regulation above. Licensee stated they will send an email to the LPA to request for a hospice increase by the end of 10/17/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Stephenie Doub

LICENSING EVALUATOR NAME:

Arielle Pascua

LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC809 (FAS) - (06/04)

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