Residential Care Services Investigation Summary Report

Provider/Facility: Golden Age Senior Care LLC (962813) Intake ID(s): 3355308

License/Cert. #: AF753113Investigator: Osterman, Pamela Region/Unit: RCS Region 2/Unit G Investigation

Date(s):07/06/201707/06/2017

through

Complainant Contact Date(s): 07/07/2017Allegations:#1. Annual licensing fee is overdue. Oldest due date: 05-15-17 $1350.00

Investigation Methods:Sample: residents Observations: AFH: TV and lights

working, caregiverpresent,

Interviews: providercurrent residents

Record Reviews: FMS DepartmentRecords, caregiverrecords

Allegation Summary:#1. On AFH tour the residents observed well groomed and clean. Two residents said they were well cared for by staff. Whenasked if the provider was aware the AFH license fee was overdue, the provider said, "I lost the billing statement, I just got busy."Records showed the AFH license fee due date 05-05-17. Record showed the AFH license fee was overdue in the amount of$1350.00.

Unalleged Violation(s):Record showed the background check for one caregiver is expired. The provider said thought background check is due everythree years.

Yes No

Conclusion /Action:

Failed Provider Practice Identified /Citation(s) Written

Failed Provider Practice Not Identified /No Citation Written

See statement of deficiencies dated 07-06-17.

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