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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306000502
Report Date: 09/22/2022
Date Signed: 09/22/2022 01:12:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/16/2020 and conducted by Evaluator Albert Marin
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20201216111753
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: DATE:
09/22/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator (AD) Glen GoldsmithTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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A resident is being mistreated by another resident while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility to deliver the final report for the investigation completed for the complaint received last December 16, 2020 against this facility. LPA met with Administrator (AD) Glen Goldsmith and stated the purpose of this visit. LPA discussed the findings.

On allegation that a resident is being mistreated by another resident while in care, based on observation, file review and interviews the following are the findings. Based June 29, 2020 Physician’s Report, Resident 1 had primary diagnosis of chronic obstructive pulmonary disease (COPD) and secondary diagnosis of a psychiatric disorder. R1 was determined to be able to follow instructions, able to communicate needs and able to leave facility unassisted. R1 was not determined to have inappropriate or aggressive behavior. Based on the observation log from January 2020 to January 2021, there had been about 13 recorded incidents wherein R1 was observed to have aggressive or disruptive behavior commonly manifested as loud screaming and disrespectful notably to staff members, and residents (Continuation in Page 2)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20201216111753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 09/22/2022
NARRATIVE
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(Continuation from Page 1)

Facility issued written warnings against these behaviors as early as June 2016, followed by warning issued on September and October 2020. On February 2021, facility issued a 30 day eviction notice against R1 on the grounds of violating the house rules in multiple occasions. Based on the above findings, the preponderance of the evidence standard has been met. Therefore, the above allegation is found SUBSTANTIATED.

Deficiency had been observed. Citations was issued per Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted an exit interview with Ad Glen Goldsmith. Copies of this report, deficiency page, and appeal rights were left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20201216111753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2022
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:
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Facility will ensure that residents are properly assessed for any potential behavior issues, and addressed new behavior issues as such by promptly referring residents to appropriate medical professional for assessment and support. Threat reduced.
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Based on observation, interviews and file review, facility missed to ensure that all residents are accorded dignity in their personal relationship with staff, residents, and other persons. R1 was observed to have about 13 incidents of verbal abuse towards staff and other residents. This posed immediate threat against personal rights of the 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) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3