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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507206765
Report Date: 06/22/2022
Date Signed: 06/22/2022 05:12:18 PM

Document Has Been Signed on 06/22/2022 05:12 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:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kenroy AndersonTIME COMPLETED:
01:00 PM
NARRATIVE
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An unannounced annual visit was conducted by Licensing Program Analysts (LPAs) Charlie Yang and Arielle Pascua. LPAs met with caregiver, Colin Falconer, who was asked to call the facility designated administrator at the time. LPAs met with Kenroy Anderson shortly after. One other staff member was present, Nadia Falconer. LPAs met with the Licensee shortly after, Marinela Placintar. This facility has a hospice waiver for 6 and a dementia program on file.

The current census was 6 residents.

A tour of this facility was conducted.

The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been annually inspected by Jorgenson Co on 03/22/2022.

The kitchen area was toured. LPAs observed a non-perishable and perishable foods in the cabinets and refrigerator. Additional perishable food supplies were identified in the garage.

LPAs observed a locked centralized stored medication cabinet located in the kitchen. Along with the administrator, the LPAs observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.

A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time.

A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022
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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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 VII
FACILITY NUMBER: 507206765
VISIT DATE: 06/22/2022
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Laundry area was toured. 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.

A tour of the garage was conducted. Additional perishable food supplies were identified.

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

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.



Appeal rights were printed and a copy was given to the facility designated Administrator.

Exit Interview.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/22/2022 05:12 PM - It Cannot Be Edited


Created By: Arielle Pascua On 06/22/2022 at 12:36 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: 06/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
8088(b)
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.
This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited since the window screens were not present and residents may not open their windows without pests entering the facility, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2022
Plan of Correction
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Licensee agreed to purchase a window screen and send the receipt and picture into the LPA's email by 6/29/2022.
Type B
Section Cited
HSC
87303(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with repairing the toilet which does not flush at the time of the visit and residents may not use it, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2022
Plan of Correction
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Licensee agrees to get the toilet fixed and send in a work order of services rendered by 06/29/2022.
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:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022


LIC809 (FAS) - (06/04)
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