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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202200
Report Date: 04/14/2023
Date Signed: 04/18/2023 12:55:07 PM

Document Has Been Signed on 04/18/2023 12:55 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 HORIZON #2FACILITY NUMBER:
275202200
ADMINISTRATOR:JOSE MARI VITANFACILITY TYPE:
735
ADDRESS:73 PALOMA AVE.TELEPHONE:
(831) 758-2139
CITY:SALINASSTATE: CAZIP CODE:
93905
CAPACITY: 25CENSUS: 24DATE:
04/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Licensee, Benjamin MacasaetTIME COMPLETED:
03:15 PM
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Licensing Program Analysts (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Licensee, Benjamin Macasaet, Continual Administrator's Certification for Richard Macasaet expires 05/16/2024. There are currently 24 residents who reside at this home. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs. Toxins and cleaning supplies are locked and inaccessible. This facility performs disaster drills as required. Water temperature was tested at 125 degrees. First Aid kit is not complete. LPA Hurt observed facility resident dressers to be broken, facility bathroom to need flooring repairs. LPA Hurt observed 4 out of 4 facility fire extinguishers have not been serviced within the required year. LPA Hurt observed the facility resident bedroom walls to be extremely dirty.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Licensee, Benjamin, Mascasaet and copy of report left at facility
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2023
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 4
Document Has Been Signed on 04/18/2023 12:55 PM - It Cannot Be Edited


Created By: Sarah Hurt On 04/14/2023 at 02:45 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
,
, CA

FACILITY NAME: NEW HORIZON #2
FACILITY NUMBER: 275202200

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

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 fire extinguishers have not been serviced in more than a year (March2022) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2023
Plan of Correction
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Licensee will provide proof of serviced fire extinguishers to LPA Hurt by 04/15/2023 POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Stephenie Doub
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/18/2023 12:55 PM - It Cannot Be Edited


Created By: Sarah Hurt On 04/14/2023 at 02:45 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
,
, CA

FACILITY NAME: NEW HORIZON #2
FACILITY NUMBER: 275202200

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 facility water temperature in resident ladies room measured to be 125 degrees which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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Licensee will send proof of water temperature being within 105 and 120 degrees to LPA Hurt by POC date of 04/28/2023.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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:Stephenie Doub
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/18/2023 12:55 PM - It Cannot Be Edited


Created By: Sarah Hurt On 04/14/2023 at 03:00 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 HORIZON #2
FACILITY NUMBER: 275202200

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80887(a)

80087 Buildings 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 LPA Hurt observed the facility walls to be extremely dirty, bathrooms need flooring repair, several bedrooms have broken dressers,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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Licensee will complete necessary repairs, and submit proof to LPA Hurt by 04/28/2023 POC date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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2
3
4
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:Brenda Chan
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023


LIC809 (FAS) - (06/04)
Page: 4 of 4