306000502-9-22-2022-22-AS-LADS-CJS4AN-20220930185614

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000502
Report Date: 09/22/2022
Date Signed: 09/22/2022 01:26:38 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
11/16/2020 and conducted by Evaluator Albert Marin

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20201116094344

FACILITY NAME:	NEW HORIZON LODGE, INC.		FACILITY NUMBER:	306000502
ADMINISTRATOR:	GLEN E GOLDSMITH		FACILITY TYPE:	740
ADDRESS:	8541 CERRITOS AVENUE		TELEPHONE:	(714) 821-5781
CITY:	STANTON	STATE: CA	ZIP CODE:	90680
CAPACITY:	120	CENSUS:	DATE:	09/22/2022
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Administrator Glen Goldsmith		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Resident wandered away from the facility

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 November 16, 2020 against this facility. LPA met with Administrator (AD) Glen Goldsmith and stated the purpose of this visit.

On allegation that resident wandered away from the facility, based on observation, file review and interviews the following are the findings. Resident 1 (R1) had been living in the facility since April 2014. R1 was placed under conservatorship. On April 2016 Physician’s Report, R1 was diagnosed with Schizophrenia, Paranoid Type; and determined to have wandering behavior, and not able to leave the facility unassisted due to conservatorship. Based on October 17, 2019 Individual Service Plan, it indicated that under conservator care permission needed to step out the facility for home pass. Based on observation logs provided, May 8, 2020, R1 violated the house rule. R1 left facility to go to store next door. R1 was brought back by staff. May 19, 2020, R1 violated house rule. Left to the liquor market and refused to listen. August 29, 2020, R1 was seen and observed to be awake all night walking up and down. There was an endorsement to follow up for further medication evaluation. (Continuation in Page 2 )

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (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-20201116094344

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)

Based on October 21,2020 Physician’s Report, Resident 1 (R1) had primary diagnosis as previously stated. R1 was determined to have no wandering behavior and able to leave the facility unassisted. R1 remained under conservatorship. On November 12, 2020 about 4:12 PM, R1 got out of the facility unassisted. No sign out log was completed. No staff member observed R1 exited the facility. About 4:30 PM, R1 was witnessed to be at the intersection of Brookhurst and Cerritos Avenue, (estimated to be about 1.4 miles from the facility) Based on medical records, R1 was brought in the emergency department of a hospital at 6:59 PM via an ambulance. Per history provided, R1 tripped and had a ground level fall with loss of consciousness for unspecified duration. R1 was eventually admitted for further evaluation and management. It was on November 13, 2020 5:24 AM, a missing person report was made to the police department. 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. Citation is 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, civil penalty assessment form, appeal rights, and cited regulation were left in the facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (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-20201116094344

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 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Facility will ensure that there are adequate staff to monitor movement of residents in and out of the facility. Threat reduced.
	8 9 10 11 12 13 14	Based on observation, file review and interviews, the facility missed to provide facility personnel ..to meet resident needs.R1 was observed to be violating the house rules on leaving the facility unassisted; and recent wander episode prior to the incident. Facility missed to provide additional services to address change of behavior of resident. This posed immediate threat on safety of resident in care.	8 9 10 11 12 13 14	Civil penalty was assessed. Copy of the cited regulation was provided for full reference.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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 Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (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