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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000502
Report Date: 09/27/2022
Date Signed: 09/27/2022 01:07:10 PM


Document Has Been Signed on 09/27/2022 01:07 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: 69DATE:
09/27/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:21 PM
MET WITH:Sarah ZarateTIME COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to New Horizon Lodge, and was temperature checked upon entering the facility. LPA Haley met with Assistant Administrator Sarah Zarate and explained the reason for today's visit.

During the investigation of complaint control #: 22-AS-20220621171421 it was discovered that Resident 1 (R1) did not have a current Physicians Report on file. The Physicians Report on file for R1 was dated May 1, 2017.

Based on R1's Individualized Service Plan Dated June 25, 2022 and the Physicians Report dated May 1, 2017 R1's has had a change in condition. This change in condition has not been documented by a Physician on a LIC602A.

During today's case management visit, deficiencies are being cited under California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted, a copy of this report, LIC809D, LIC811, and appeal rights was provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022
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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Document Has Been Signed on 09/27/2022 01:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2022
Section Cited

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87463 Reappraisals
(c) licensee shall arrange a meeting with the resident, the resident's representative... If any, whent there is significant change in the resident's condition, or once every 12 months, which ever occurs first, as specified in section 87467, Resident Participation in Decision Making.
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This requirement is not being met as evidenced by:
During record review, LPA observed R1's Physicians Reported was dated May 1, 2017.
This poses a potential health and safety risk to residents 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: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022
LIC809 (FAS) - (06/04)
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