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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507206765
Report Date: 06/17/2021
Date Signed: 06/20/2021 08:33:14 PM

Document Has Been Signed on 06/20/2021 08:33 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 VIIFACILITY NUMBER:
507206765
ADMINISTRATOR:PLACINTAR, BIANCAFACILITY TYPE:
740
ADDRESS:1709 MABLE AVETELEPHONE:
(209) 495-2504
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 6DATE:
06/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Marinela Placintar, LicenseeTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced annual / Infection Control visit on this date. LPA was greeted by Bella Patello Caregiver. LPA met with Marinela Placintar , Administrator.

LPA and administrator inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, and dining room areas. LPA observed sufficient 7 days non-perishable and 2 days perishable food supplies.. Hot water temperature measured at 108.1 degrees in residents bathroom with the AD which is in required range of 105 to 120 degrees. Last Fire Drill conduced dated 6/1//21. Fire extinguisher maintained, Fire alarm and carbon monoxide functional. LPA and administrator observed centrally stored medications. LPA reviewed staff and resident files. LPA observed resident emergency contact complete but dated 2021. LPA observed resident practicing social distancing. LPA observed sharps and toxins locked.

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 to administrator.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2021
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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Document Has Been Signed on 06/17/2021 06:36 PM - It Cannot Be Edited


Created By: Arlene D Garcia On 06/17/2021 at 12:47 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 VII
FACILITY NUMBER: 507206765

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/17/2021
Section Cited

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80036. Licensing Fees(b)(1) In addition to fees set forth in subdivision (a), the department shall charge the following fees:
(F) A late fee that represents an additional 50 percent of the established annual fee when any licensee fails to pay the annual licensing fee on or before the due date as indicated by postmark on the payment.

This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply with the section cited above in paying annual fees timely, which poses/posed a potential health, safety or personal rights risk to persons 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: 06/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2021


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