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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206657
Report Date: 05/04/2023
Date Signed: 05/04/2023 02:43:37 PM

Document Has Been Signed on 05/04/2023 02:43 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:NEW HORIZONS HOMES COMMUNITY CARE FAC. INC. #2FACILITY NUMBER:
157206657
ADMINISTRATOR:WYATT, LORIFACILITY TYPE:
735
ADDRESS:409 SPERRY STREETTELEPHONE:
(661) 792-3831
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY: 6CENSUS: 6DATE:
05/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Administrator Lori WyattTIME COMPLETED:
02:45 PM
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On 5/4/2023, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct
an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by staff Justin Fielding. House supervisor Ravi (Tony) Peiris and Administrator Lori Wyatt was contacted and would be arriving shortly.

All pathways, entrances and exits were clear from obstructions. LPA and Administrator began the tour at the facility kitchen. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Tour continued to the living room. At 12:30 LPA observed the living room carpet to have spills and was mated in areas. Tour continued to Residents Rooms. LPA toured three shared bedrooms which were observed to be furnished with required furniture and adequate lighting. Fire extinguisher in hallway was last serviced on 1/17/2023 and was fully charged. Linen supply is kept in the laundry room. Cleaning supplies and chemicals are kept locked in staff office. Medications are kept in the Kitchen cabinet. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. Staff files were reviewed for good health. Staff files had First Aid training. LPA observed sufficient seating under covered patio area in the back of the facility.

Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22,
Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 5/25/2023: Current copy
of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization
(LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan
(LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

Exit interview was conducted. Report signed on-site; printed copy of report provided with appeal rights.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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 05/04/2023 02:43 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 05/04/2023 at 02:11 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: NEW HORIZONS HOMES COMMUNITY CARE FAC. INC. #2
FACILITY NUMBER: 157206657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 4 out of 4, LPA observed Living room and bedroom carpet to have debris and spills in need of cleaning which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2023
Plan of Correction
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Administrator agrees to look into hiring a outside contractor or schedule facility maintenance to complete the carpet cleaning.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:See Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023


LIC809 (FAS) - (06/04)
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