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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206660
Report Date: 04/07/2022
Date Signed: 04/07/2022 05:39:53 PM

Document Has Been Signed on 04/07/2022 05:39 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:NEW HORIZONS HOMES COMMUNITY CARE FAC.INC.#5FACILITY NUMBER:
157206660
ADMINISTRATOR:FRANKLIN, R. & BORDERS, S.FACILITY TYPE:
735
ADDRESS:4512 HAHN AVENUETELEPHONE:
(661) 396-1371
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 6CENSUS: 5DATE:
04/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Lori Wyatt, Co-Administrator
Joye Walker, House Manager		TIME COMPLETED:
11:20 AM
NARRATIVE
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On 4/7/22 at 9:05 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry by staff. Co-Administrator Lori Wyatt and House Manager Joye Walker arrived a short time later. There were two staff and five residents present during the inspection.

LPA toured inside and outside of facility with staff. No obstructions or fire clearance issues observed. LPA observed COVID-19 precaution signs posted and screening at entrance. Hand sanitizer was available to residents and visitors. Social distancing is maintained in the common and dining areas. Bedrooms were checked and two of three bedrooms are shared rooms. LPA checked residents’ medications and observed the month's supply. Cleaning and PPE supplies were checked. Main PPE supply is stored at the main office. Food supply was observed sufficient. Sample of staff records checked for current health assessments. Administrator certification is valid.

The following deficiencies were observed:
1. Living room top window screen observed bent on bottom left and middle right sides.

The following update forms to be sent to CCL within 2 weeks:
LIC500, LIC610D (new revision), LIC400, LIC402

Deficiencies are being cited based on LPA's observations and interview in accordance with the California Code of Regulations, Title 22, see LIC809D.

Exit interview conducted. Due to COVID-19 precautionary measures, a copy of this report and appeal rights were emailed to email on record with "Read receipt" to confirm receipt of this report. LPA verified email on record is correct.

SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
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 5
Document Has Been Signed on 04/07/2022 05:39 PM - It Cannot Be Edited


Created By: Malia Thao On 04/07/2022 at 11:03 AM
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.#5
FACILITY NUMBER: 157206660

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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. Living room top window screen observed bent on bottom left and middle right sides, which poses a potential health or safety risk to persons in care.
POC Due Date: 04/15/2022
Plan of Correction
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Co-Administrator states proof of replacement or repair of living room top window screen will be sent to CCL by POC due date.
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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022


LIC809 (FAS) - (06/04)
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