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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005492
Report Date: 11/27/2023
Date Signed: 11/28/2023 08:36:57 AM

Document Has Been Signed on 11/28/2023 08:36 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GOLDEN AGE VIFACILITY NUMBER:
507005492
ADMINISTRATOR:TRAIAN OANCEAFACILITY TYPE:
740
ADDRESS:2008 DAMASK COURTTELEPHONE:
(209) 495-2504
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 6DATE:
11/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kenroy Anderson TIME COMPLETED:
11:00 AM
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On 11/27/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA met with Kenroy Anderson and explained the purpose of the visit.

The purpose of this visit was to follow up on a Decision and Order in regards to S1 who was deemed to be excluded from being present, employed, or have any contact with any licensed facility by the Department.
It was learned that S1 was asked to leave the facility on 11/12/2023 and has not been present in this facility since that date.

A tour of the facility was conducted to confirm S1 was not present.

There were no deficiencies observed or cited during today's case management visit.

An exit interview was conducted and a copy of this report was provided to the facility.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2023
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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