<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507206765
Report Date: 05/06/2024
Date Signed: 05/06/2024 01:52:26 PM

Document Has Been Signed on 05/06/2024 01:52 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GOLDEN AGE VIIFACILITY NUMBER:
507206765
ADMINISTRATOR/
DIRECTOR:		PLACINTAR, BIANCAFACILITY TYPE:
740
ADDRESS:1709 MABLE AVETELEPHONE:
(209) 495-2504
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 5DATE:
05/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Kenroy AndersonTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/06/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA met with Caregiver, Colin Falconer and explained the purpose of the visit. LPA asked Caregiver Falconer call the Licensee to inform them that CCL was present. LPA learned that the Licensee and the Facility Designated Administrator were unable to come to the facility at this time. Shortly after, LPA met with Facility Designated Representative (FDR), Kenroy Anderson and explained the purpose of the visit.

Current census was 5. A brief interview with FDR Anderson was conducted.

A tour of the facility was conducted. The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been purchased with a receipt attached to it with a date of 05/06/2024.
The kitchen area was toured. LPA observed a pantry with selected canned goods such as, 6 cans of tuna, 6 spaghetti noodles, and around 15 cans of vegetables and fruit. LPA observed some frozen meat in the freezer and one bell pepper, a cabbage, a jug of milk, one jug of apple juice, prune juice and a bag of carrots. LPA informed FDR Anderson that this was not a sufficient amount of food supply at this time.
Additional perishable food supplies were identified in the garage.

LPA observed a locked centralized stored medication cabinet located in the kitchen. Along with the administrator, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. It was observed that the facility was obtaining over the counter medication for residents without a prescription order. The LPA informed FDR Anderson that all over the counter medications need a prescription or doctors order. 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: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN AGE VII
FACILITY NUMBER: 507206765
VISIT DATE: 05/06/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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.

Due to insufficient time, the LPA will come at a later date to complete the annual visit.

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: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/06/2024 01:52 PM - It Cannot Be Edited


Created By: Arielle Pascua On 05/06/2024 at 01:33 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN AGE VII
FACILITY NUMBER: 507206765

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in not ensuring that there was a sufficient amount of one week nonperishable food supply and a minumum of two day perishable food supply was maintained on the premsises. LPA observed around 31 cans of food including but not limited to, tuna, fruit, vegetable, and pastas. In addition, it was observed that the refrigerator had one jug of milk, a jug apple juice and prune juice. This poses an immediate health, safety and personal rights risks to persons in care.
POC Due Date: 05/06/2024
Plan of Correction
1
2
3
4
The licensee shall ensure that there is a sufficient amount of food supply at all times. Licensee stated a food order will be sent to the facility by the end of day. A copy of the food receipt as well as a photo of food supply shall be sent to the LPA by the POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Lisa Rios
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/06/2024 01:52 PM - It Cannot Be Edited


Created By: Arielle Pascua On 05/06/2024 at 01:40 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN AGE VII
FACILITY NUMBER: 507206765

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.
This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, record review, and interview, the licesee did not comply with the section cited above but not ensuring that 4 out 4 residents did not have a prescription label or doctors orders for their over-the-counter medication. This poses a potential health, safety, or personal rights risks to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
1
2
3
4
Licensee shall ensure that all over-the-counter medication has prescription or doctor's orders. A statement of acknowledgement and correction shall be sent to the LPA by the POC Date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Lisa Rios
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4