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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005174
Report Date: 04/27/2022
Date Signed: 04/28/2022 07:45:02 AM

Document Has Been Signed on 04/28/2022 07:45 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 VFACILITY NUMBER:
507005174
ADMINISTRATOR:OANCEA, TRAIANFACILITY TYPE:
740
ADDRESS:3301 SHARON AVENUETELEPHONE:
(209) 495-2504
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 6DATE:
04/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Donald Stewart - CaregiverTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced 1 Year Required Annual Inspection Visit. LPA met with caregiver and explained purpose of visit. Current census is 6 residents with 3 on Hospice. Administrator Certificate expires 10/06/2022.
LPA and administrator inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, laundry room, and dining room area. LPA observed sufficient seven days non-perishable and two days perishable food supplies in the main kitchen. LPA observed centrally stored medications. Hot water temperature was measured in kitchen sink and it measured at 107.2 F degrees which is in the required range of 105 to 120 degrees. LPA observed there was a Carbon Monoxide monitor in facility. LPA observed cabinet under sink in kitchen was locked and toxins stored under sink. LPA verified the last Fire Drill was conducted . Fire Extinguishers expire 03/18/2023. Staff and visitors enter the facility through ringing the locked front door, sanitizer, thermometer, sign in sheets were observed. COVID-19 signs posted in front entry way.
LPA reviewed (4) staff files. All staff is fingerprint cleared and associated to the facility and staff currently have First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils. LPA reviewed 5 resident files which have all Community Care Licensing (CCL) documents as required.. LPA reviewed 3 of resident medication files, which were completed .
LPA requested the following documents to be submitted via email to Community Care Licensing (CCL) by 05/26/2022: ruth.wallace@dss.ca.gov
LIC 308 Designation of Facility Responsibility
LIC 500 Personnel Report
Copy Administrator Certificate
Copy Current Liability Insurance - 06/25/2022

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 direct care staff and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2022
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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