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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005174
Report Date: 05/27/2021
Date Signed: 05/27/2021 04:30:01 PM

Document Has Been Signed on 05/27/2021 04:30 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 VFACILITY NUMBER:
507005174
ADMINISTRATOR:OANCEA, TRAIANFACILITY TYPE:
740
ADDRESS:3301 SHARON AVENUETELEPHONE:
(209) 495-2504
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 6DATE:
05/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marinela Placintar-Administrator TIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Arlene Garcia and (LPA) Albert Johnson conducted an unannounced annual / Infection Control visit on this date. LPAs were greeted by Venice Andrews, Caregiver. LPAs met with Administrator, Marinela Placintar.

LPAs and administrator inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, laundry room, and dining room area. LPAs observed sufficient seven days non-perishable and two days perishable food supplies in the main kitchen. LPAs and administrator observed centrally stored medications. Hot water temperature was measured in residents' bathroom with the Administrator and measured at 115 degrees which is in the required range of 105 to 120 degrees. LPAs observed there was a Carbon Monoxide monitor in facility.
LPAs observed cabinet under sink in kitchen not locked and toxins stored under sink.

LPAs verified the last FireDrill was conducted May 2021. The emergency disaster and training was completed on April 26, 2021.

Cont on 809-C >>>>>>>>>>>>>>>>>>>>>>>
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2021
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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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 V
FACILITY NUMBER: 507005174
VISIT DATE: 05/27/2021
NARRATIVE
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Staff and visitors enter the facility through ringing the locked front door, sanitizer, thermometer, sign in sheets were observed. COVID signs posted in front entry way.

LPAs reviewed 2 staff files and 5 resident files. While reviewing resident files, LPAs observed: both staff files missing TB and Health Screen, 1 of 5 residents (R1) was missing updated 602/Physicians Report.

LPAs requested an updated 602/Resident Files for R1 and TB/ Health screen for employees. Administrator stated they had employee files at main office as they were working with Guardian to have all Golden Age employee associated to all facilities. Administrator at main office was able to fax over one of the employees TB and Health Screen.

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 held with Marinela Placintar and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/27/2021 04:30 PM - It Cannot Be Edited


Created By: Arlene D Garcia On 05/27/2021 at 01:11 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN AGE V
FACILITY NUMBER: 507005174

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/27/2021
Section Cited

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Care of Persons with Dementia (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants shall be inaccessible to residents with dementia.
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This requirement has not been met as evidenced by: The Licensee did not ensure toxins were locked as LPAs observed cleaning supplies and toxins under sink with a broken lock. This violation posses an immediate health and safety risk to the residents 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:Stephenie Doub
LICENSING EVALUATOR NAME:Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/27/2021 04:30 PM - It Cannot Be Edited


Created By: Arlene D Garcia On 05/27/2021 at 01:23 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOLDEN AGE V
FACILITY NUMBER: 507005174

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/27/2021
Section Cited

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87506(b)(1-17) (A-F)
Resident Records
The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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This requirement is not met as evidenced by: Based on review of resident files and observation of documentation, the licensee did not ensure resident records upto date as required by Title 22 Regulations. This violation poses a potential health, and safety risk to residents 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:Stephenie Doub
LICENSING EVALUATOR NAME:Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2021


LIC809 (FAS) - (06/04)
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