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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507206765
Report Date: 07/11/2022
Date Signed: 07/12/2022 08:53:50 AM

Document Has Been Signed on 07/12/2022 08:53 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 VIIFACILITY NUMBER:
507206765
ADMINISTRATOR:PLACINTAR, BIANCAFACILITY TYPE:
740
ADDRESS:1709 MABLE AVETELEPHONE:
(209) 495-2504
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 6DATE:
07/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Kenroy AndersonTIME COMPLETED:
01:15 PM
NARRATIVE
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An unannounced plan of correction visit was conducted on 07/11/2022 by Licensing Program Analysts (LPAs) Arielle Pascua and Avellina Martinez. LPA Arielle Pascua and LPA Avellina Martinez met with the designated, authorized representative, Kenroy Anderson and explained the purpose of today's visit.

The purpose of this visit was to clear the deficiencies that were cited on the last annual visit on 06/22/2022.
During this visit LPAs toured the facility and it was discovered that the laundry room was left open with accessible toxins. It was also observed that two people were not wearing masks and hand sanitizer dispenser was empty.
One deficiency was not cleared LPA observed front window screen was not repaired. The screen was bend and not properly sealed allowing for air to come through into the facility.
  • Facility staff was informed an immediate civil penalty of $1,200 was assessed for a violation of Section 8088(b) on 07/11/2022. This civil penalty was due to not clearing Plan of Correction (POC) that was not cleared by POC date 06/29/2022.
  • Facility staff was informed an immediate civil penalty of $500 was assessed for a violation of Section Health and Safety Code 1569.50(a)(3) on 07/11/2022.

As a result of this visit, deficiencies were cited per California Code of Regulations, Title 22 and Health and Safety Code. Exit interview was conducted, and a copy of 809, 809D, and appeals rights were given to the facility at the end of visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2022
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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Document Has Been Signed on 07/12/2022 08:53 AM - It Cannot Be Edited


Created By: Arielle Pascua On 07/11/2022 at 12:33 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: 07/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/12/2022
Section Cited
CCR
87309(a)

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87309(a) Storage Space
Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement was not met as evidence by based on observation
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Licensee agrees to lock laundry room and made toxins inaccesible to the residents in care. POC was cleared at the time of visit.
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Licensee did not ensure toxins were accesible to residents in care. LPAs observed toxins unlocked in laundry room. This posed an immediate health and safety risk for residents in care.
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Type A
07/12/2022
Section Cited
HSC1569.50(a)(3)

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Health and Safety Code 1569.50(a)(3)
Conduct Inimical: Conduct which is inimical to health, morals, welfare or safety of either an individual in, or receiving services from the facility or the people of the State of California. This requirement was not met as evidenced by
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Facility Staff agrees to: to train all staff on covid-19 precautionary measures by POC Date 07/12/2022.
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based on observation the facility did not implement mask mandate for both staff and visitors. This poses an immediate 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:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022


LIC809 (FAS) - (06/04)
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