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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440848
Report Date: 01/25/2021
Date Signed: 01/25/2021 12:36:36 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:
01/25/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Cris Utleg/StaffTIME COMPLETED:
11:30 AM
NARRATIVE
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On this date, January 25, 2021, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management inspection to ensure the excluded individual (S1) is not present in the facility.

LPA met with staff, Maria Sheila Tiangco. LPA verified if S1 is in the facility. LPA met with S1 who indicated she is the manager of this facility and licensee's other 2 facilities, New Horizons (Home # 2 for the Aged) and New Horizons # 3.

LPA called and spoke with Rosario Utleg, license. Ms. Utleg indicated she can not come to the facility. LPA also met with Cris Utleg, staff. LPA informed both Cris Utleg and Rosario Utleg regarding S1.

Based on the information obtained, a deficiency is cited from Title 22 California Code of Regulation (see 809D). A $500.00 civil penalty is assessed on this day.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment and copy of this report provided to Cris Ulteg.
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021
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: 01/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/25/2021
Section Cited

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87777 Exclusions (a) The Department may prohibit an individual from serving as a board of directors, executive director, or officer; being employed or allowed in a licensed facility as specified in Health and Safety Code Sections 1569.58 and 1569.59.

This requirement is not met as evidenced by:
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-Based on observation and interview, the licensee did not comply with the above Regulation by allowing S1 be present in the facility which poses immediate health and safety risks to persons 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: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2021
LIC809 (FAS) - (06/04)
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