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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440848
Report Date: 09/30/2020
Date Signed: 09/30/2020 02:16:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:NEW HORIZONS (HOME #1 FOR THE AGED)FACILITY NUMBER:
011440848
ADMINISTRATOR:SOFIA NEWFACILITY TYPE:
740
ADDRESS:5115 FOOTHILL BLVD.TELEPHONE:
(510) 261-1112
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY:15CENSUS: 10DATE:
09/30/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sofia New, AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
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On Wednesday, September 30, 2020 at 1:00 PM, Licensing Program Analyst (LPA) C. Phomphachanh contacted facility to conduct case management for incident reported on 09/21/2020. LPA met with Cris Utleg, Administrator for New Horizons #2 for the Aged and Sofia New, Administrator for New Horizons #1 for the Aged through tele-visit via face-time. LPA explained reason of the call. Due to the Shelter in Place set forth by the Governor on March 17, 2020 until further notice, LPA was not able to conduct the visit in person.

LPA explained to both Administrators about filing timely incident reports for AWOL and Death Reports: verbally within 24 hours and submit LIC 624 Unusual Incident/Injury Report and LIC 624A Death Report within 7 days of reporting to Community Care Licensing (CCL). LPA went over regulation 87211 Reporting Requirement with both Administrators.

Due to the untimely reporting, LPA issued a deficiency. California Code of Regulations, Title 22 Sec 87211(a)(2) Reporting Requirement, is being cited on the attached LIC 809D. Failure to correct deficiency by POC date may result in civil penalties

Exit interview conducted with both Administrators, Sofia New and Cris Utleg. Copy of report sent PDF via email with appeals rights.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2020
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: NEW HORIZONS (HOME #1 FOR THE AGED)
FACILITY NUMBER: 011440848
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/01/2020
Section Cited

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87211 Reporting Requirements
(a) Each licensee shall report...
(2) Occurrences.. major accidents which threaten the welfare, safety or health of residents.., shall be reported within 24 hours either by telephone or facsimile to the licensing agency ...when appropriate.
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This requirement was not met as evidenced by:

Based on observation, on 09/21/2020 via email Administrator sent incident report to CCL for incident occurrence on 09/09/2020 for AWOL of resident. Therefore, this is an immediate health and safety risk for 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: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2020
LIC809 (FAS) - (06/04)
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