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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004860
Report Date: 10/29/2024
Date Signed: 10/29/2024 03:50:36 PM

Document Has Been Signed on 10/29/2024 03:50 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 IVFACILITY NUMBER:
507004860
ADMINISTRATOR/
DIRECTOR:		ELENA TRITEANFACILITY TYPE:
740
ADDRESS:3109 IRON GATE DR.TELEPHONE:
(209) 495-2504
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 5DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Venice AndrewsTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 10/29/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA met with staff member (SM), Antonieta Gimeno and explained the purpose of the visit. Shortly after, LPA met with Facility Designated Representative (FDR), Venice Andrews. There was one staff member present, Damian Campbell.

Current census was 5. A brief interview with FDR Andrews was conducted. This facility has a hospice waiver for 2 and a dementia program on file.
LPA reviewed 4 resident files and 3 staff files. All files were complete and up to date. The facility administrator has an active administrator certificate #7018208740 and expires on 03/24/2025.
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 08/21/2024.
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: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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 IV
FACILITY NUMBER: 507004860
VISIT DATE: 10/29/2024
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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

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 the facility.

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

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
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