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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000502
Report Date: 08/23/2022
Date Signed: 08/23/2022 01:41:17 PM


Document Has Been Signed on 08/23/2022 01:41 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:NEW HORIZON LODGE, INC.FACILITY NUMBER:
306000502
ADMINISTRATOR:GLEN E GOLDSMITHFACILITY TYPE:
740
ADDRESS:8541 CERRITOS AVENUETELEPHONE:
(714) 821-5781
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY:120CENSUS: 63DATE:
08/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Administrator Glen GoldsmithTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management visit at New Horizon Lodge. LPA was greeted, granted entry by staff and explained the reason for the visit. LPA Haley met with Administrator Glen Goldsmith.

The purpose of today's visit was to conduct a Case Management visit to discuss an Unusual Incident Report (LIC 624) that was sent to the Orange County Adult and Senior Care Regional Office August 22, 2022.

On today's visit LPA Haley conducted interviews with residents and staff regarding the incident involving Resident 1 (R1) on July 31, 2022. AD Goldsmith will be emailing a copy of R1's Admission Agreement, Individual Service Plan and Physicians Report.

No deficiencies are being cited during today's Case Management visit. An exit interview was conducted and a copy of this report and LIC 811 was provided.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
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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